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

Yusuf Mushlih; Imam Adli; Leo Alfath Araysi; Kemal Akbar Suryoadji; Rinaldo Indra Rachman; Ghifari Nurullah; Roberto Bagaskara Indy Christanto; Missy Savira; Rupin Shah; Ashok Agarwal; Indah Suci Widyahening; Gita Pratama; Gede Wirya Kusuma Duarsa; Ricky Adriansjah; Dyandra Parikesit; Widi Atmoko; Nur Rasyid; Ponco Birowo

doi:10.12688/f1000research.136305.2

Home Browse Knowledge, attitudes, and practices regarding male infertility: A...

ALL Metrics

Views

Downloads

Get PDF

Get XML

Export

▬

✚

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, 1 approved with reservations]

Yusuf Mushlih¹, Imam Adli¹, Leo Alfath Araysi¹, [...] Kemal Akbar Suryoadji¹, Rinaldo Indra Rachman^2,3, Ghifari Nurullah³, Roberto Bagaskara Indy Christanto^1,3, Missy Savira^1-3, Rupin Shah^2,4, Ashok Agarwal^2,5, Indah Suci Widyahening⁶, Gita Pratama⁷, Gede Wirya Kusuma Duarsa^2,8, Ricky Adriansjah^2,9, Dyandra Parikesit^2,10, Widi Atmoko^2,3,10, Nur Rasyid^2,3, Ponco Birowo^2,3

Yusuf Mushlih¹, Imam Adli¹, [...] Leo Alfath Araysi¹, Kemal Akbar Suryoadji¹, Rinaldo Indra Rachman^2,3, Ghifari Nurullah³, Roberto Bagaskara Indy Christanto^1,3, Missy Savira^1-3, Rupin Shah^2,4, Ashok Agarwal^2,5, Indah Suci Widyahening⁶, Gita Pratama⁷, Gede Wirya Kusuma Duarsa^2,8, Ricky Adriansjah^2,9, Dyandra Parikesit^2,10, Widi Atmoko^2,3,10, Nur Rasyid^2,3, Ponco Birowo^2,3

PUBLISHED 21 Jul 2025

Author details Author details

¹ Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
² Global Andrology Forum, Moreland Hills, OH, USA
³ Department of Urology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
⁴ Department of Urology, Lilavati Hospital & Research Centre, Mumbai, India
⁵ Cleveland Clinic, Cleveland, OH, USA
⁶ Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
⁷ Department of Obstetrics & Gynecology, Faculty of Medicine, University of Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
⁸ Department of Urology, Faculty of Medicine, Universitas Udayana, Prof. Dr. I.G.N.G Ngoerah General Hospital, Denpasar, Bali, Indonesia
⁹ Department of Urology, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin General Hospital,, Bandung, Indonesia
¹⁰ Department of Urology, Faculty of Medicine, Universitas Indonesia, Universitas Indonesia Hospital, Jakarta, Indonesia

Yusuf Mushlih
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Imam Adli
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Leo Alfath Araysi
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Kemal Akbar Suryoadji
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Rinaldo Indra Rachman
Roles: Conceptualization, Funding Acquisition, Investigation, Project Administration, Writing – Review & Editing

Ghifari Nurullah
Roles: Funding Acquisition, Investigation, Project Administration, Writing – Review & Editing

Roberto Bagaskara Indy Christanto
Roles: Writing – Review & Editing

Missy Savira
Roles: Writing – Review & Editing

Rupin Shah
Roles: Writing – Review & Editing

Ashok Agarwal
Roles: Writing – Review & Editing

Indah Suci Widyahening
Roles: Supervision, Writing – Review & Editing

Gita Pratama
Roles: Supervision, Writing – Review & Editing

Gede Wirya Kusuma Duarsa
Roles: Conceptualization, Investigation, Writing – Review & Editing

Ricky Adriansjah
Roles: Investigation, Writing – Review & Editing

Dyandra Parikesit
Roles: Conceptualization, Investigation, Writing – Review & Editing

Widi Atmoko
Roles: Writing – Review & Editing

Nur Rasyid
Roles: Writing – Review & Editing

Ponco Birowo
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

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, 1 approved with reservations]. 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.

See the authors' detailed response to the review by Hong-Jun Li

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 17^th, 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
Male	201 (53.2)
Female	177 (46.8)
Age group
≥35 years	268 (70.9)
<35 years	110 (29.1)
Education level
Middle school	2 (0.5)
High school	33 (8.7)
Higher education	343 (90.7)
Occupation
Private sector employee	141 (37.3)
Civil servant/armed forces/policeman/employee at a state-owned enterprise	106 (28)
Entrepreneur	53 (14.0)
Other	46 (12.2)
Unemployed	25 (6.6)
Student	6 (1.6)
Laborer/driver/housemaid	1 (0.3)
Monthly income
<5 million rupiah	72 (19.0)
5–10 million rupiah	135 (35.7)
>10 million rupiah	171 (45.2)
Health insurance
National health insurance (BPJS)	146 (38.6)
Private health insurance	56 (14.8)
Both BPJS and private health insurance	149 (39.4)
Do not have health insurance	27 (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).

Statement	Adequate knowledge
Statement	Total n (%)	Men n (%)	Women n (%)
History of urinary tract infection is related to male infertility	271 (71.7)	156 (77.6)	115 (65.0)
Hormonal imbalance is related to male infertility	367 (97.1)	197 (98.0)	170 (96.0)
Constant high temperature around the male genitalia is related to male infertility	279 (73.8)	149 (74.1)	130 (73.4)
History of sexually transmitted diseases is related to male infertility	350 (92.6)	182 (90.5)	168 (94.9)
Age is related to male infertility	211 (55.8)	121 (60.2)	90 (50.8)
Smoking is related to male infertility	331 (87.6)	176 (87.6)	155 (87.6)
Excessive alcohol consumption is related to male infertility	343 (90.7)	179 (89.1)	164 (92.7)
Obesity is related to male infertility	347 (91.8)	181 (90.0)	166 (93.8)
Chronic diseases (diabetes, hypertension, and cardiovascular diseases) are related to male infertility	326 (86.2)	173 (86.1)	207 (68.8)
Psychological stress and mental disorders are related to male infertility	332 (87.8)	177 (88.1)	155 (87.6)
History of recreational drug use is related to male infertility	345 (91.3)	182 (90.5)	163 (92.1)
Supernatural causes are related to male infertility	342 (90.5)	276 (87.6)	166 (93.8)
Black magic is related to male infertility	350 (92.6)	175 (87.1)	175 (98.9)
Regular exercise is related to male infertility	349 (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).

Item	Positive attitudes
Item	Total n (%)	Men n (%)	Women n (%)
Male infertility is a disease	170 (45.0)	94 (46.8)	76 (42.9)
Couples experiencing infertility need to be treated and given treatment	364 (96.3)	193 (96)	171 (96.6)
Male infertility can be cured	339 (89.7)	178 (88.6)	161 (91.0)
Male infertility is a serious medical problem	265 (70.1)	143 (71.1)	122 (68.9)
Treatment of infertility in men is dangerous	297 (78.6)	151 (75.1)	146 (82.5)
Infertility in men should be treated medically	359 (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 child	326 (86.2)	172 (85.6)	154 (87.0)
The ability to have children is greatly affected by health	358 (94.7)	191 (95.0)	167 (94.4)
The ability to have children is greatly affected by the partner’s health	347 (91.8)	182 (90.5)	165 (93.2)
Infertility can reduce my quality of life	178 (47.1)	104 (51.7)	74 (51.8)
Having children is the right of every human being	332 (87.8)	177 (88.1)	155 (87.6)
The community is responsible for helping couples who do not have children	137 (36.2)	84 (41.8)	53 (29.9)
Infertility is a disability	46 (12.2)	36 (17.9)	10 (5.6)
The wife should be the first to check for infertility in infertile couples	187 (49.5)	92 (45.8)	95 (53.7)
The husband should be the first to be checked for infertility in infertile couples	176 (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).

Item	Good practices n (%)
Not use traditional/alternative medicine	221 (58.5)
No/quit smoking	337 (89.2)
No/quit drinking alcohol	358 (94.7)
Adequate consumption of nutritious foods	328 (86.8)
Adopted healthier lifestyle	339 (89.7)
No using drugs without prescription	268 (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)
Urologist	68 (18.0)
The first to be tested for infertility
Husband	43 (11.4)
Wife	151 (39.9)
Together	184 (48.7)
History of in-vitro fertilization
Yes	124 (67.2)
No	254 (32.8)
History of child adoption
Yes	13 (3.4)
No	365 (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).

Item	Level of insight
Item	Poor n (%)	Moderate n (%)	Good n (%)
Knowledge	17 (4.5)	108 (28.6)	253 (66.9)
Attitudes	2 (0.5)	102 (27.0)	274 (72.5)
Husband’s practices	34 (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.

Relationship	r-value	p
Knowledge and attitudes	0.280	0.016
Knowledge and husband’s practices	0.140	0.186
Attitudes and husband’s practices	0.251	0.031

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.

Characteristic	n (%)	“Good” level of
		Knowledge		Attitudes		Husband practices
		OR (95% CI)	p	OR (95% CI)	p	OR (95% CI)	p
Gender
Male	201 (53.2)	0.91 (0.58–1.42)	0.67	0.79 (0.49– 1.27)	0.33	0.72 (0.45–1.14)	0.16
Female^†	177 (46.8)	0.91 (0.58–1.42)	0.67	0.79 (0.49– 1.27)	0.33	0.72 (0.45–1.14)	0.16
Age group
≥35 Years	268 (70.9)	0.89 (0.54–1.45)	0.63	0.97 (0.57–1.62)	0.89	1.18 (0.70–1.95)	0.53
<35^†	110 (29.1)	0.89 (0.54–1.45)	0.63	0.97 (0.57–1.62)	0.89	1.18 (0.70–1.95)	0.53
Education level
Higher education	343 (90.7)	0.72 (0.33–1.58)	0.42	1.74 (0.83–3.66)	0.14	1.91 (0.92–3.98)	0.08
Lower education^†	35 (9.2)	0.72 (0.33–1.58)	0.42	1.74 (0.83–3.66)	0.14	1.91 (0.92–3.98)	0.08
Monthly income
≥10 million rupiah	171 (45.3)	1.93 (1.21–3.06)	0.01	1.61 (0.99–2.63)	0.056	1.14 (0.714–1.83)	0.58
<10 million rupiah^†	207 (54.7)	1.93 (1.21–3.06)	0.01	1.61 (0.99–2.63)	0.056	1.14 (0.714–1.83)	0.58
Health insurance
Have health insurance	351 (92.9)	0.61 (0.24–1.51)	0.28	0.70 (0.27–1.80)	0.45	1.21 (0.52–2.82)	0.65
Do not have health insurance^†	27 (7.1)	0.61 (0.24–1.51)	0.28	0.70 (0.27–1.80)	0.45	1.21 (0.52–2.82)	0.65

† 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

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).

References

1. Zegers-Hochschild F, Adamson GD, de Mouzon J , et al.: International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) revised glossary of ART terminology, 2009. Fertil. Steril. 2009; 92(5): 1520–1524. PubMed Abstract | Publisher Full Text
2. World Health Organization: International Classification of Diseases, 11th Revision (ICD-11). Geneva: WHO; 2019.
3. Kumar N, Singh AK: Trends of male factor infertility, an important cause of infertility: a review of literature. Journal of human reproductive sciences. 2015; 8(4): 191–196. PubMed Abstract | Publisher Full Text | Free Full Text
4. Greenhall E, Vessey M: The prevalence of subfertility: a review of the current confusion and a report of two new studies. Fertil. Steril. 1990; 54(6): 978–983. PubMed Abstract | Publisher Full Text
5. World Health Organization: WHO Manual for the Standardized Investigation and Diagnosis of the Infertile Couple. Cambridge: Cambridge University Press; 2000.
6. Ali S, Sophie R, Imam AM, et al.: Knowledge, perceptions and myths regarding infertility among selected adult population in Pakistan: a cross-sectional study. BMC Public Health. 2011; 11: 760. PubMed Abstract | Publisher Full Text | Free Full Text
7. Mumtaz Z, Shahid U, Levay A: Understanding the impact of gendered roles on the experiences of infertility amongst men and women in Punjab. Reprod. Health. 2013; 10: 3. PubMed Abstract | Publisher Full Text | Free Full Text
8. Chu KY, Patel P, Ramasamy R: Consideration of gender differences in infertility evaluation. Curr. Opin. Urol. 2019; 29(3): 267–271. PubMed Abstract | Publisher Full Text
9. Harzif AK, Santawi VPA, Wijaya S: Discrepancy in perception of infertility and attitude towards treatment options: Indonesian urban and rural area. Reprod. Health. 2019; 16(1): 126. PubMed Abstract | Publisher Full Text | Free Full Text
10. Jarvi K, Lau S, Lo K, et al.: MP19-09: results of a North American survey on the characteristics of men presenting for infertility investigations: The Andrology Research Consortium. J. Urol. 2018; 199(4S): e247. Publisher Full Text
11. Birowo P: Semen parameter profile of infertile men visiting andro-urology clinic. eJournal Kedokteran Indonesia. 2020; 8(2): 88–92. Publisher Full Text
12. Nieschlag E, Behre HM, Nieschlag S, editors. Andrology: Male reproductive health and dysfunction. Berlin: Springer Verlag; 2010. Publisher Full Text
13. Chiba K, Enatsu N, Fujisawa M: Management of non-obstructive azoospermia. Reproductive medicine and biology. 2016; 15(3): 165–173. PubMed Abstract | Publisher Full Text | Free Full Text
14. Chinnaiyan S, Babu B: Knowledge, attitude, and practices about male infertility among men and women in slums of Chennai, Tamil Nadu: a cross-sectional study. Int. J. Community Med. Public Health. 2020; 7(10): 3996–4000. Publisher Full Text
15. Gerhard RS, Ritenour CW, Goodman M, et al.: Awareness of and attitudes towards infertility and its treatment: a cross-sectional survey of men in a United States primary care population. Asian J. Androl. 2014; 16(6): 858–863. PubMed Abstract | Publisher Full Text | Free Full Text
16. Abolfotouh MA, Alabdrabalnabi AA, Albacker RB, et al.: Knowledge, attitude, and practices of infertility among Saudi couples. Int. J. Gen. Med. 2013; 6: 563–573. PubMed Abstract | Publisher Full Text | Free Full Text
17. Harris ID, Fronczak C, Roth L, et al.: Fertility and the aging male. Rev. Urol. 2011; 13(4): e184–e190.
18. George K, Kamath MS: Fertility and age. J. Hum. Reprod. Sci. 2010; 3(3): 121–123. PubMed Abstract | Publisher Full Text | Free Full Text
19. Kesehatan K, Riset L: Basic Health Research Report (Riskesdas) 2018. Jakarta: Badan Litbangkes, Kemenkes RI; 2019. Reference Source
20. Sugiharto E: Tingkat kesejahteraan masyarakat nelayan desa benua baru ilir berdasarkan indikator badan pusat statistik. [The Welfare Level of Fishermen Communities in Benua Baru Ilir Village Based on Indicators from the Central Bureau of Statistics]. EPP. 2007; 4(2): 32–36. Reference Source
21. Feleke BT, Wale MZ, Yirsaw MT: Knowledge, attitude and preventive practice towards COVID-19 and associated factors among outpatient service visitors at Debre Markos compressive specialized hospital, north-west Ethiopia, 2020. PLoS One. 2021; 16(7): e0251708. PubMed Abstract | Publisher Full Text | Free Full Text
22. Rea LM, Parker RA: Designing and conducting survey research: a comprehensive guide. 2nd ed.Hoboken, New Jersey: Jossey-Bass; 1992.
23. Boadi-Kusi SB, Holdbrook S, Kyei S, et al.: Knowledge, Attitudes and Practices of Postnatal Mothers on Ophthalmia Neonatorum in the Central Region, Ghana. Health Serv. Insights. 2021; 14:11786329211033248. PubMed Abstract | Publisher Full Text | Free Full Text
24. Koni A, Taha S, Daifallah A, et al.: A cross-sectional evaluation of knowledge, attitudes, practices, and perceived challenges among Palestinian pharmacists regarding COVID-19. SAGE Open Medicine. 2022; 10:20503121211069278. PubMed Abstract | Publisher Full Text | Free Full Text
25. Ashebir W, Yimer B, Alle A, et al.: Knowledge, attitude, practice, and factors associated with prevention practice towards COVID-19 among healthcare providers in Amhara region, northern Ethiopia: A multicenter cross-sectional study. PLOS Glob. Public Health. 2022; 2(4):e0000171. PubMed Abstract | Publisher Full Text | Free Full Text
26. Bennett LR, Wiweko B, Bell L, et al.: Reproductive knowledge and patient education needs among Indonesian women infertility patients attending three fertility clinics. Patient Educ. Couns. 2015; 98(3): 364–369. PubMed Abstract | Publisher Full Text
27. Carlsen E, Giwercman A, Keiding N, et al.: Evidence for decreasing quality of semen during past 50 years. BMJ (Clinical research ed.). 1992; 305(6854): 609–613. PubMed Abstract | Publisher Full Text | Free Full Text
28. Swan SH, Elkin EP, Fenster L: The question of declining sperm density revisited: an analysis of 101 studies published 1934-1996. Environ. Health Perspect. 2000; 108(10): 961–966. PubMed Abstract | Publisher Full Text | Free Full Text
29. Jørgensen N, Vierula M, Jacobsen R, et al.: Recent adverse trends in semen quality and testis cancer incidence among Finnish men. Int. J. Androl. 2011; 34(4 Pt 2): e37–e48. PubMed Abstract | Publisher Full Text | Free Full Text
30. Feki NC, Abid N, Rebai A, et al.: Semen quality decline among men in infertile relationships: experience over 12 years in the South of Tunisia. J. Androl. 2009; 30(5): 541–547. PubMed Abstract | Publisher Full Text
31. Fido A: Emotional distress in infertile women in Kuwait. Int. J. Fertil. Womens Med. 2004; 49(1): 24–28. PubMed Abstract
32. Schlegel PN, Sigman M, Collura B, et al.: Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline Part I. J. Urol.2021;205(1):36–43. Publisher Full Text PubMed Abstract |
33. Mehta A, Nangia AK, Dupree JM, et al.: Limitations and barriers in access to care for male factor infertility. Fertil. Steril.2016;105(5):1128–1137. Publisher Full Text PubMed Abstract |
34. Konsil Kedokteran Indonesia: Persebaran Dokter Berdasarkan Alamat Korespondensi [Geographical Distribution of Doctors by Correspondence Address]. 2022; Jakarta: KKI.
35. Daumler D, Chan P, Lo KC, et al.: Men’s knowledge of their own fertility: a population-based survey examining the awareness of factors that are associated with male infertility. Hum. Reprod.2016;31(12):2781–2790.Publisher Full Text | PubMed Abstract | Free Full Text
36. Iktidar MA, Chowdhury S, Roy S, et al.: Knowledge, attitude and perception among medical students and healthcare professionals regarding male infertility: a cross-sectional survey from Bangladesh. BMJ Open. 2022; 12(11):e062251. PubMed Abstract | Publisher Full Text | Free Full Text
37. Pemerintah Indonesia: Peraturan Pernerintah Republik Indonesia Nomor 61 Tahun 2014 tentang Kesehatan Reproduksi [Government Regulation of the Republic of Indonesia Number 61 of 2014 on Reproductive Health].2014. Reference Source
38. Menteri Kesehatan Republik Indonesia: Peraturan Menteri Kesehatan Republik Indonesia Nomor 43 Tahun 2015 Tentang Penyelenggaraan Pelayanan Reproduksi dengan Bantuan atau Kehamilan di Luar Cara Alamiah. [Regulation of the Minister of Health of the Republic of Indonesia Number 43 of 2015 on the Implementation of Assisted Reproductive Services or Pregnancy by Non-Natural Means].2015.Reference Source
39. BPJS Kesehatan: Panduan layanan bagi peserta BPJS kesehatan [Service Guidelines for BPJS Health Participants]. 2020; Jakarta: BPJS Kesehatan. Reference Source
40. Swift BE, Liu KE: The effect of age, ethnicity, and level of education on fertility awareness and duration of infertility. J. Obstet. Gynaecol. Can. 2014; 36(11): 990–996. Publisher Full Text
41. De Jonge CJ, Gellatly SA, Vazquez-Levin MH, et al.: Male Attitudes towards Infertility: Results from a Global Questionnaire. World J. Mens Health.2023;41(1):204–214. Publisher Full Text | PubMed Abstract | Free Full Text
42. Eisenberg ML, Lathi RB, Baker VL, et al.: Frequency of the Male Infertility Evaluation: Data from the National Survey of Family Growth. J. Urol.2013;189(3):1030–1034.Publisher Full Text PubMed Abstract |
43. Chandra A, Copen CE, Stephen EH: Infertility service use in the United States: data from the National Survey of Family Growth, 1982-2010. Natl. Health Stat. Report.2014; 73:1–21.
44. Sharifi F, Jamali J, Larki M, et al.: Domestic violence against infertile women: a systematic review and meta-analysis. Sultan Qaboos Univ. Med. J. 2022; 22(1): 14–27. PubMed Abstract | Publisher Full Text | Free Full Text
45. American Urological Association: Practicing urologist in the United States 2022 . 2023; Maryland: AUA.
46. Ofasu-Budu D, Hänninen V: Ways of reducing the stigma of infertility: views of infertile women and their herbalists. Afr. J. Reprod. Health. 2021; 25(2): 110. Publisher Full Text
47. Aljassim N, Ostini R: Health literacy in rural and urban populations: a systematic review. Patient Educ. Couns. 2020; 103(10): 2142–2154. PubMed Abstract | Publisher Full Text
48. Almeida-Santos T, Melo C, Macedo A, et al.: Are women and men well informed about fertility? childbearing intentions, fertility knowledge and information-gathering sources in Portugal. Reprod. Health. 2017; 14(1): 91. PubMed Abstract | Publisher Full Text | Free Full Text
49. McLernon DJ, Steyerberg EW, Velde ER, et al.: Predicting the chances of a live birth after one or more complete cycles of in vitro fertilisation: population based study of linked cycle data from 113 873 women. BMJ. 2016; 355(i5735):27852632. PubMed Abstract | Publisher Full Text | Free Full Text
50. Direktorat Statistik Kependudukan dan Ketenagakerjaan: Booklet Survei Angkatan Kerja Nasional Agustus 2022 [Booklet of the August 2022 National Labor Force Survey]. 2022; Jakarta: Badan Pusat Statistik.
51. Valsangkar S, Bodhare T, Bele S, et al.: An evaluation of the effect of infertility on marital, sexual satisfaction indices and health-related quality of life in women. J. Hum. Reprod. Sci. 2011; 4(2): 80–85. PubMed Abstract | Publisher Full Text | Free Full Text
52. Nyarko SH, Amu H: Self-reported effects of infertility on marital relationships among fertility clients at a public health facility in Accra, Ghana. Fertil. Res. Pract. 2015; 1: 10. PubMed Abstract | Publisher Full Text | Free Full Text
53. Hawkins AJ, Willoughby BJ, Doherty WJ: Reasons for divorce and openness to marital reconciliation. J. Divorce Remarriage. 2012; 53(6): 453–463. Publisher Full Text
54. Welz AN, Emberger-Klein A, Menrad K: Why people use herbal medicine: insights from a focus-group study in Germany. BMC Complement. Altern. Med. 2018; 18(1): 92. PubMed Abstract | Publisher Full Text | Free Full Text
55. Akbaribazm M, Goodarzi N, Rahimi M: Female infertility and herbal medicine: an overview of the new findings. Food Sci. Nutr. 2021; 9(10): 5869–5882. PubMed Abstract | Publisher Full Text | Free Full Text
56. Kashani L, Akhondzadeh S: Female infertility and herbal medicine. J. Med. Plants. 2017; 16(61): 3–7.
57. Anh NH, Kim SJ, Long NP, et al.: Ginger on human health: A comprehensive systematic review of 109 randomized controlled trials. Nutrients. 2020; 12(1): 157. PubMed Abstract | Publisher Full Text | Free Full Text
58. Ahmad S, Campos MG, Fratini F, et al.: New insights into the biological and pharmaceutical properties of royal jelly. Int. J. Mol. Sci. 2020; 21(2): 382. PubMed Abstract | Publisher Full Text | Free Full Text
59. Suleiman JB, Bakar ABA, Mohamed M: Review on bee products as potential protective and therapeutic agents in male reproductive impairment. Molecules. 2021; 26(11): 3421. PubMed Abstract | Publisher Full Text | Free Full Text
60. Pedro J, Brandão T, Schmidt L, et al.: What do people know about fertility? a systematic review on fertility awareness and its associated factors. Ups. J. Med. Sci. 2018; 123(2): 71–81. PubMed Abstract | Publisher Full Text | Free Full Text
61. Ahmadi H, Montaser-Kouhsari L, Nowroozi MR, et al.: Male infertility and depression: a neglected problem in the Middle East. J. Sex. Med. 2011; 8(3): 824–830. PubMed Abstract | Publisher Full Text
62. Fisher JR, Hammarberg K: Psychological and social aspects of infertility in men: an overview of the evidence and implications for psychologically informed clinical care and future research. Asian J. Androl. 2012; 14(1): 121–129. PubMed Abstract | Publisher Full Text | Free Full Text
63. Birowo P, Mushlih Y, Adli, et al.: Knowledge, Attitudes, and Practices Regarding Male Infertility; A Cross-Sectional Study Among Infertile Couples Visiting Fertility Clinics in Indonesia’s Urban Areas. [Dataset]. 2023, July 28. Publisher Full Text

Comments on this article Comments (0)

Version 2

VERSION 2 PUBLISHED 16 Oct 2023

Author details Author details

Yusuf Mushlih
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Imam Adli
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Leo Alfath Araysi
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Kemal Akbar Suryoadji
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing

Rinaldo Indra Rachman
Roles: Conceptualization, Funding Acquisition, Investigation, Project Administration, Writing – Review & Editing

Ghifari Nurullah
Roles: Funding Acquisition, Investigation, Project Administration, Writing – Review & Editing

Roberto Bagaskara Indy Christanto
Roles: Writing – Review & Editing

Missy Savira
Roles: Writing – Review & Editing

Rupin Shah
Roles: Writing – Review & Editing

Ashok Agarwal
Roles: Writing – Review & Editing

Indah Suci Widyahening
Roles: Supervision, Writing – Review & Editing

Gita Pratama
Roles: Supervision, Writing – Review & Editing

Gede Wirya Kusuma Duarsa
Roles: Conceptualization, Investigation, Writing – Review & Editing

Ricky Adriansjah
Roles: Investigation, Writing – Review & Editing

Dyandra Parikesit
Roles: Conceptualization, Investigation, Writing – Review & Editing

Widi Atmoko
Roles: Writing – Review & Editing

Nur Rasyid
Roles: Writing – Review & Editing

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.

Article Versions (2)

version 2

Revised

Published: 21 Jul 2025, 12:1334

https://doi.org/10.12688/f1000research.136305.2

version 1

Published: 16 Oct 2023, 12:1334

https://doi.org/10.12688/f1000research.136305.1

© 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.

Download

Export To

metrics

	Views	Downloads
F1000Research	-	-
PubMed Central Data from PMC are received and updated monthly.	-	-

Citations

SEE MORE DETAILS

CITE

how to cite this article

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, 1 approved with reservations]. F1000Research 2025, 12:1334 (https://doi.org/10.12688/f1000research.136305.2)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

track

receive updates on this article

Track an article to receive email alerts on any updates to this article.

Open Peer Review

Version 2

VERSION 2

PUBLISHED 21 Jul 2025

Revised

Views

Reviewer Report 10 Sep 2025

Ashutosh Vashisht, Augusta University, Augusta, Georgia, USA

Approved with Reservations

https://doi.org/10.5256/f1000research.185199.r407707

While the topic of male infertility knowledge, attitudes, and practices (KAP) in Indonesian infertile couples is important and underexplored, the current version has several methodological, analytical, and interpretational limitations that weaken its contribution. The study presents interesting findings, but concerns regarding questionnaire reliability, representativeness of the sample, potential biases in data collection, and insufficient depth in the discussion warrant substantial revision before the work can be considered for indexing. I recommend the following major revisions for this manuscript.

Introduction:

Why is the introduction heavily focused on global and U.S./Pakistan statistics without sufficient Indonesia-specific data on male infertility prevalence, potentially overstating the problem's universality? Please give appropriate references.
The claim that stereotypes lead to "misdiagnosis" and "undertreated cases" is asserted without proper addressal. Authors need to cite direct studies on diagnostic errors.
The introduction mentions azoospermia rates (53% in Indonesia vs. 10% guideline) but attributes it to misdiagnosis without exploring alternative explanations like selection bias in clinic attendees. Critically evaluate this.
How does the aim to "Knowledge, attitudes, and practices" address the broader societal norms mentioned, when the sample is limited to infertile couples, potentially missing insights from fertile or general populations?
References like 6-8 emphasize female blame, but why not critically discuss counterevidence or cultural variations in male infertility stigma within Indonesia?

Methods:

The Cronbach's alpha for knowledge (0.607) and attitudes (0.669) is suboptimal, why proceed without revising the questionnaire for better reliability, and how might this affect result validity?
The practice section scores only men's behaviors (6 questions), ignoring couples' practices, why this asymmetry, and how does it bias interpretations of overall couple dynamics?
Bloom's cutoff is used for categorization, but it's arbitrary and not validated for infertility KAP. Why have authors not used data driven thresholds?
The logistic regression model included multiple sociodemographic factors, was multicollinearity checked?

Results:

Correlations are weak (r<0.3), yet described as "moderate", why not adhere to standard classifications (e.g., Rea & Parker). Don’t you think this overstatement affects interpretations?
Logistic regression shows income significance for knowledge but borderline for attitudes (p=0.056)—why not discuss non-significance or power issues from small sample?
Only 45% agreed infertility is a disease, I think it contradicts the high “positive attitude” classification.
Gender differences are reported as non-significant, but tables show trends (e.g., women higher on some attitudes). There is no exploratory analysis or acknowledgment of potential underpowering.
Practices like IVF history (67.2%) are high, but there is no breakdown by duration of infertility or prior treatments to contextualize these figures.

Discussion:

The discussion attributes obstetrician preference to stigma without direct evidence from data. Add appropriate references.
Authors need to discuss the weak reliability of the knowledge/attitude scales discussed as a limitation.
Calls for policy changes (e.g., more urologists) are speculative, but authors need to tie them to data (e.g., 18% urologist visits) and critically assess feasibility in Indonesia's healthcare system.
The authors link findings to global sperm quality decline, which I think is overstretching beyond study evidence.
The discussion does not quantify or analyze gender-related stigma effectively.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Reproductive Biology, Molecular Pathology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

CITE

Report a concern

Respond or Comment

Views

Reviewer Report 14 Aug 2025

Hong-Jun Li, Department of Urology, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China

Approved

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

CITE

Report a concern

Respond or Comment

Version 1

VERSION 1

PUBLISHED 16 Oct 2023

Views

Reviewer Report 24 Oct 2023

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

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 areas visited an obstetrician-gynecologist first rather than a urologist, despite having good knowledge, attitudes, and practices regarding male infertility. Overall, this work is well designed and completed, but still have some defects:

This research included 378 participants (210 men and 177 women). Compared to the more prevalence of infertility, the sample size was limited. Due to the limited sample size, this made the heterogeneity large, and subgroup analysis impossible.
Last sentence of conclusion in abstract (The government needs to conduct health education and further public health efforts regarding male infertility to reduce the negative stigma and misperceptions about infertility in society) can be deleted. This is only a suggestion or discussion content, and not based on research outcomes of the paper.
How to definite the good knowledge, positive attitudes, and good practices were an important problem. The questionnaires should be carefully designed and validating. The authors should give more discussion in discussion part.
Of course, the stigma (women are to blame for infertility in a relationship remains prevalent worldwide) causes many women to be depressed and self-deprecating. From other view, male infertility is not given enough attention, and this may also a reflection that the ability (diagnosis and treatment of male infertility) and attitude towards male infertility are not good enough. The authors can discuss about the serious situation for management of male fertility in discussion part.
Some of references might not be proper and should be changed or deleted, including references number 14, 20, 22, 32, 33, 34.

All in all, this work was well done, had some value, and could be published as data or information, but some revision needs to be done before it can be approved for indexing.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Male infertility

CITE

Report a concern

Author Response 10 Sep 2025

Ponco Birowo, Department of Urology Faculty of Medicine Universitas Indonesia/ CIpto Mangunkusumo Hospital, Indonesia

10 Sep 2025

Author Response

R: This research included 378 participants (210 men and 177 women). Compared to the more prevalence of infertility, the sample size was limited. Due to the limited sample size, this ... Continue reading R: This research included 378 participants (210 men and 177 women). Compared to the more prevalence of infertility, the sample size was limited. Due to the limited sample size, this made the heterogeneity large, and subgroup analysis impossible.
A: We acknowledge the limitations in the sample size of our study and we’ve added more detail in the strength and limitation section. However, the sample size was predetermined based on the population of male infertility patients across three infertility clinics in Jakarta, Bandung, and Denpasar. The estimated population size is approximately 15,000 patients. With margin of error of 5% and a confidence level of 95%, a minimum of 375 samples is required for this study.

R: Last sentence of conclusion in abstract (The government needs to conduct health education and further public health efforts regarding male infertility to reduce the negative stigma and misperceptions about infertility in society) can be deleted. This is only a suggestion or discussion content, and not based on research outcomes of the paper.
A: Thank you for your feedback, we corrected this.

R: How to definite the good knowledge, positive attitudes, and good practices were an important problem. The questionnaires should be carefully designed and validating. The authors should give more discussion in discussion part.
A: We use Bloom’s cutoff ratio to define KAP levels, where a score of less than 60% is considered poor, a score between 60% and 79% is categorized as moderate, and a score of 80% to 100% is considered good. Bloom’s cutoff is the most widely used and cited standard for KAP studies, and we elaborate on this in detail in the discussion section.

R: Of course, the stigma (women are to blame for infertility in a relationship remains prevalent worldwide) causes many women to be depressed and self-deprecating. From other view, male infertility is not given enough attention, and this may also a reflection that the ability (diagnosis and treatment of male infertility) and attitude towards male infertility are not good enough. The authors can discuss about the serious situation for management of male fertility in discussion part.
A: Thank you for your feedback. We agree that the lack of attention and the limitations of male infertility management should be discussed more. We've added this discussion in the corresponding section, specifically paragraphs 4-6.

R: Some of references might not be proper and should be changed or deleted, including references number 14, 20, 22, 32, 33, 34.
A: We’ve changed and/or deleted references number 14, 20, 22, 32, 33, 34. We've also added English translations for our Indonesian references.
R: This research included 378 participants (210 men and 177 women). Compared to the more prevalence of infertility, the sample size was limited. Due to the limited sample size, this made the heterogeneity large, and subgroup analysis impossible.
A: We acknowledge the limitations in the sample size of our study and we’ve added more detail in the strength and limitation section. However, the sample size was predetermined based on the population of male infertility patients across three infertility clinics in Jakarta, Bandung, and Denpasar. The estimated population size is approximately 15,000 patients. With margin of error of 5% and a confidence level of 95%, a minimum of 375 samples is required for this study.

R: Last sentence of conclusion in abstract (The government needs to conduct health education and further public health efforts regarding male infertility to reduce the negative stigma and misperceptions about infertility in society) can be deleted. This is only a suggestion or discussion content, and not based on research outcomes of the paper.
A: Thank you for your feedback, we corrected this.

R: How to definite the good knowledge, positive attitudes, and good practices were an important problem. The questionnaires should be carefully designed and validating. The authors should give more discussion in discussion part.
A: We use Bloom’s cutoff ratio to define KAP levels, where a score of less than 60% is considered poor, a score between 60% and 79% is categorized as moderate, and a score of 80% to 100% is considered good. Bloom’s cutoff is the most widely used and cited standard for KAP studies, and we elaborate on this in detail in the discussion section.

R: Of course, the stigma (women are to blame for infertility in a relationship remains prevalent worldwide) causes many women to be depressed and self-deprecating. From other view, male infertility is not given enough attention, and this may also a reflection that the ability (diagnosis and treatment of male infertility) and attitude towards male infertility are not good enough. The authors can discuss about the serious situation for management of male fertility in discussion part.
A: Thank you for your feedback. We agree that the lack of attention and the limitations of male infertility management should be discussed more. We've added this discussion in the corresponding section, specifically paragraphs 4-6.

R: Some of references might not be proper and should be changed or deleted, including references number 14, 20, 22, 32, 33, 34.
A: We’ve changed and/or deleted references number 14, 20, 22, 32, 33, 34. We've also added English translations for our Indonesian references.
Competing Interests: No competing interests were disclosed. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 10 Sep 2025

Ponco Birowo, Department of Urology Faculty of Medicine Universitas Indonesia/ CIpto Mangunkusumo Hospital, Indonesia

10 Sep 2025

Author Response

R: This research included 378 participants (210 men and 177 women). Compared to the more prevalence of infertility, the sample size was limited. Due to the limited sample size, this ... Continue reading R: This research included 378 participants (210 men and 177 women). Compared to the more prevalence of infertility, the sample size was limited. Due to the limited sample size, this made the heterogeneity large, and subgroup analysis impossible.
A: We acknowledge the limitations in the sample size of our study and we’ve added more detail in the strength and limitation section. However, the sample size was predetermined based on the population of male infertility patients across three infertility clinics in Jakarta, Bandung, and Denpasar. The estimated population size is approximately 15,000 patients. With margin of error of 5% and a confidence level of 95%, a minimum of 375 samples is required for this study.

R: Last sentence of conclusion in abstract (The government needs to conduct health education and further public health efforts regarding male infertility to reduce the negative stigma and misperceptions about infertility in society) can be deleted. This is only a suggestion or discussion content, and not based on research outcomes of the paper.
A: Thank you for your feedback, we corrected this.

R: How to definite the good knowledge, positive attitudes, and good practices were an important problem. The questionnaires should be carefully designed and validating. The authors should give more discussion in discussion part.
A: We use Bloom’s cutoff ratio to define KAP levels, where a score of less than 60% is considered poor, a score between 60% and 79% is categorized as moderate, and a score of 80% to 100% is considered good. Bloom’s cutoff is the most widely used and cited standard for KAP studies, and we elaborate on this in detail in the discussion section.

R: Of course, the stigma (women are to blame for infertility in a relationship remains prevalent worldwide) causes many women to be depressed and self-deprecating. From other view, male infertility is not given enough attention, and this may also a reflection that the ability (diagnosis and treatment of male infertility) and attitude towards male infertility are not good enough. The authors can discuss about the serious situation for management of male fertility in discussion part.
A: Thank you for your feedback. We agree that the lack of attention and the limitations of male infertility management should be discussed more. We've added this discussion in the corresponding section, specifically paragraphs 4-6.

R: Some of references might not be proper and should be changed or deleted, including references number 14, 20, 22, 32, 33, 34.
A: We’ve changed and/or deleted references number 14, 20, 22, 32, 33, 34. We've also added English translations for our Indonesian references.
R: This research included 378 participants (210 men and 177 women). Compared to the more prevalence of infertility, the sample size was limited. Due to the limited sample size, this made the heterogeneity large, and subgroup analysis impossible.
A: We acknowledge the limitations in the sample size of our study and we’ve added more detail in the strength and limitation section. However, the sample size was predetermined based on the population of male infertility patients across three infertility clinics in Jakarta, Bandung, and Denpasar. The estimated population size is approximately 15,000 patients. With margin of error of 5% and a confidence level of 95%, a minimum of 375 samples is required for this study.

R: Last sentence of conclusion in abstract (The government needs to conduct health education and further public health efforts regarding male infertility to reduce the negative stigma and misperceptions about infertility in society) can be deleted. This is only a suggestion or discussion content, and not based on research outcomes of the paper.
A: Thank you for your feedback, we corrected this.

R: How to definite the good knowledge, positive attitudes, and good practices were an important problem. The questionnaires should be carefully designed and validating. The authors should give more discussion in discussion part.
A: We use Bloom’s cutoff ratio to define KAP levels, where a score of less than 60% is considered poor, a score between 60% and 79% is categorized as moderate, and a score of 80% to 100% is considered good. Bloom’s cutoff is the most widely used and cited standard for KAP studies, and we elaborate on this in detail in the discussion section.

R: Of course, the stigma (women are to blame for infertility in a relationship remains prevalent worldwide) causes many women to be depressed and self-deprecating. From other view, male infertility is not given enough attention, and this may also a reflection that the ability (diagnosis and treatment of male infertility) and attitude towards male infertility are not good enough. The authors can discuss about the serious situation for management of male fertility in discussion part.
A: Thank you for your feedback. We agree that the lack of attention and the limitations of male infertility management should be discussed more. We've added this discussion in the corresponding section, specifically paragraphs 4-6.

R: Some of references might not be proper and should be changed or deleted, including references number 14, 20, 22, 32, 33, 34.
A: We’ve changed and/or deleted references number 14, 20, 22, 32, 33, 34. We've also added English translations for our Indonesian references.
Competing Interests: No competing interests were disclosed. Close
Report a concern

Comments on this article Comments (0)

Version 2

VERSION 2 PUBLISHED 16 Oct 2023

Open Peer Review

Reviewer Status

Reviewer Reports

	Invited Reviewers
	1	2
Version 2 (revision) 21 Jul 25	read	read
Version 1 16 Oct 23	read

Hong-Jun Li, Chinese Academy of Medical Sciences, Beijing, China
Ashutosh Vashisht, Augusta University, Augusta, USA

Comments on this article

All Comments(0)

Add a comment

Browse by related subjects

Back to all reports

Reviewer Report

1 Views

10 Sep 2025 | for Version 2

Ashutosh Vashisht, Augusta University, Augusta, Georgia, USA

1 Views Cite this report Responses(0)

Approved With Reservations

Why is the introduction heavily focused on global and U.S./Pakistan statistics without sufficient Indonesia-specific data on male infertility prevalence, potentially overstating the problem's universality? Please give appropriate references.
The claim that stereotypes lead to "misdiagnosis" and "undertreated cases" is asserted without proper addressal. Authors need to cite direct studies on diagnostic errors.
The introduction mentions azoospermia rates (53% in Indonesia vs. 10% guideline) but attributes it to misdiagnosis without exploring alternative explanations like selection bias in clinic attendees. Critically evaluate this.
How does the aim to "Knowledge, attitudes, and practices" address the broader societal norms mentioned, when the sample is limited to infertile couples, potentially missing insights from fertile or general populations?
References like 6-8 emphasize female blame, but why not critically discuss counterevidence or cultural variations in male infertility stigma within Indonesia?

Methods:

The Cronbach's alpha for knowledge (0.607) and attitudes (0.669) is suboptimal, why proceed without revising the questionnaire for better reliability, and how might this affect result validity?
The practice section scores only men's behaviors (6 questions), ignoring couples' practices, why this asymmetry, and how does it bias interpretations of overall couple dynamics?
Bloom's cutoff is used for categorization, but it's arbitrary and not validated for infertility KAP. Why have authors not used data driven thresholds?
The logistic regression model included multiple sociodemographic factors, was multicollinearity checked?

Results:

Correlations are weak (r<0.3), yet described as "moderate", why not adhere to standard classifications (e.g., Rea & Parker). Don’t you think this overstatement affects interpretations?
Logistic regression shows income significance for knowledge but borderline for attitudes (p=0.056)—why not discuss non-significance or power issues from small sample?
Only 45% agreed infertility is a disease, I think it contradicts the high “positive attitude” classification.
Gender differences are reported as non-significant, but tables show trends (e.g., women higher on some attitudes). There is no exploratory analysis or acknowledgment of potential underpowering.
Practices like IVF history (67.2%) are high, but there is no breakdown by duration of infertility or prior treatments to contextualize these figures.

Discussion:

The discussion attributes obstetrician preference to stigma without direct evidence from data. Add appropriate references.
Authors need to discuss the weak reliability of the knowledge/attitude scales discussed as a limitation.
Calls for policy changes (e.g., more urologists) are speculative, but authors need to tie them to data (e.g., 18% urologist visits) and critically assess feasibility in Indonesia's healthcare system.
The authors link findings to global sperm quality decline, which I think is overstretching beyond study evidence.
The discussion does not quantify or analyze gender-related stigma effectively.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Reproductive Biology, Molecular Pathology

Respond to this report

Responses (0)

Back to all reports

Reviewer Report

1 Views

14 Aug 2025 | for Version 2

Hong-Jun Li, Department of Urology, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China

1 Views Cite this report Responses(0)

Approved

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Male infertility

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

Responses (0)

Back to all reports

Reviewer Report

58 Views

24 Oct 2023 | for Version 1

Hong-Jun Li, Department of Urology, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China

58 Views Cite this report Responses(1)

Approved With Reservations

This research included 378 participants (210 men and 177 women). Compared to the more prevalence of infertility, the sample size was limited. Due to the limited sample size, this made the heterogeneity large, and subgroup analysis impossible.
Last sentence of conclusion in abstract (The government needs to conduct health education and further public health efforts regarding male infertility to reduce the negative stigma and misperceptions about infertility in society) can be deleted. This is only a suggestion or discussion content, and not based on research outcomes of the paper.
How to definite the good knowledge, positive attitudes, and good practices were an important problem. The questionnaires should be carefully designed and validating. The authors should give more discussion in discussion part.
Of course, the stigma (women are to blame for infertility in a relationship remains prevalent worldwide) causes many women to be depressed and self-deprecating. From other view, male infertility is not given enough attention, and this may also a reflection that the ability (diagnosis and treatment of male infertility) and attitude towards male infertility are not good enough. The authors can discuss about the serious situation for management of male fertility in discussion part.
Some of references might not be proper and should be changed or deleted, including references number 14, 20, 22, 32, 33, 34.

All in all, this work was well done, had some value, and could be published as data or information, but some revision needs to be done before it can be approved for indexing.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Male infertility

Respond to this report

Responses (1)

Author Response

10 Sep 2025

Ponco Birowo, Department of Urology Faculty of Medicine Universitas Indonesia/ CIpto Mangunkusumo Hospital, Indonesia

R: This research included 378 participants (210 men and 177 women). Compared to the more prevalence of infertility, the sample size was limited. Due to the limited sample size, this made the heterogeneity large, and subgroup analysis impossible.
A: We acknowledge the limitations in the sample size of our study and we’ve added more detail in the strength and limitation section. However, the sample size was predetermined based on the population of male infertility patients across three infertility clinics in Jakarta, Bandung, and Denpasar. The estimated population size is approximately 15,000 patients. With margin of error of 5% and a confidence level of 95%, a minimum of 375 samples is required for this study.

R: Last sentence of conclusion in abstract (The government needs to conduct health education and further public health efforts regarding male infertility to reduce the negative stigma and misperceptions about infertility in society) can be deleted. This is only a suggestion or discussion content, and not based on research outcomes of the paper.
A: Thank you for your feedback, we corrected this.

R: How to definite the good knowledge, positive attitudes, and good practices were an important problem. The questionnaires should be carefully designed and validating. The authors should give more discussion in discussion part.
A: We use Bloom’s cutoff ratio to define KAP levels, where a score of less than 60% is considered poor, a score between 60% and 79% is categorized as moderate, and a score of 80% to 100% is considered good. Bloom’s cutoff is the most widely used and cited standard for KAP studies, and we elaborate on this in detail in the discussion section.

R: Of course, the stigma (women are to blame for infertility in a relationship remains prevalent worldwide) causes many women to be depressed and self-deprecating. From other view, male infertility is not given enough attention, and this may also a reflection that the ability (diagnosis and treatment of male infertility) and attitude towards male infertility are not good enough. The authors can discuss about the serious situation for management of male fertility in discussion part.
A: Thank you for your feedback. We agree that the lack of attention and the limitations of male infertility management should be discussed more. We've added this discussion in the corresponding section, specifically paragraphs 4-6.

R: Some of references might not be proper and should be changed or deleted, including references number 14, 20, 22, 32, 33, 34.
A: We’ve changed and/or deleted references number 14, 20, 22, 32, 33, 34. We've also added English translations for our Indonesian references.

View more View less

Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

[1] 1. Zegers-Hochschild F, Adamson GD, de Mouzon J , et al.: International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) revised glossary of ART terminology, 2009. Fertil. Steril. 2009; 92(5): 1520–1524. PubMed Abstract | Publisher Full Text

[2] 2. World Health Organization: International Classification of Diseases, 11th Revision (ICD-11). Geneva: WHO; 2019.

[3] 3. Kumar N, Singh AK: Trends of male factor infertility, an important cause of infertility: a review of literature. Journal of human reproductive sciences. 2015; 8(4): 191–196. PubMed Abstract | Publisher Full Text | Free Full Text

[4] 4. Greenhall E, Vessey M: The prevalence of subfertility: a review of the current confusion and a report of two new studies. Fertil. Steril. 1990; 54(6): 978–983. PubMed Abstract | Publisher Full Text

[5] 5. World Health Organization: WHO Manual for the Standardized Investigation and Diagnosis of the Infertile Couple. Cambridge: Cambridge University Press; 2000.

[6] 6. Ali S, Sophie R, Imam AM, et al.: Knowledge, perceptions and myths regarding infertility among selected adult population in Pakistan: a cross-sectional study. BMC Public Health. 2011; 11: 760. PubMed Abstract | Publisher Full Text | Free Full Text

[7] 7. Mumtaz Z, Shahid U, Levay A: Understanding the impact of gendered roles on the experiences of infertility amongst men and women in Punjab. Reprod. Health. 2013; 10: 3. PubMed Abstract | Publisher Full Text | Free Full Text

[8] 8. Chu KY, Patel P, Ramasamy R: Consideration of gender differences in infertility evaluation. Curr. Opin. Urol. 2019; 29(3): 267–271. PubMed Abstract | Publisher Full Text

[9] 9. Harzif AK, Santawi VPA, Wijaya S: Discrepancy in perception of infertility and attitude towards treatment options: Indonesian urban and rural area. Reprod. Health. 2019; 16(1): 126. PubMed Abstract | Publisher Full Text | Free Full Text

[10] 10. Jarvi K, Lau S, Lo K, et al.: MP19-09: results of a North American survey on the characteristics of men presenting for infertility investigations: The Andrology Research Consortium. J. Urol. 2018; 199(4S): e247. Publisher Full Text

[11] 11. Birowo P: Semen parameter profile of infertile men visiting andro-urology clinic. eJournal Kedokteran Indonesia. 2020; 8(2): 88–92. Publisher Full Text

[12] 12. Nieschlag E, Behre HM, Nieschlag S, editors. Andrology: Male reproductive health and dysfunction. Berlin: Springer Verlag; 2010. Publisher Full Text

[13] 13. Chiba K, Enatsu N, Fujisawa M: Management of non-obstructive azoospermia. Reproductive medicine and biology. 2016; 15(3): 165–173. PubMed Abstract | Publisher Full Text | Free Full Text

[14] 14. Chinnaiyan S, Babu B: Knowledge, attitude, and practices about male infertility among men and women in slums of Chennai, Tamil Nadu: a cross-sectional study. Int. J. Community Med. Public Health. 2020; 7(10): 3996–4000. Publisher Full Text

[15] 15. Gerhard RS, Ritenour CW, Goodman M, et al.: Awareness of and attitudes towards infertility and its treatment: a cross-sectional survey of men in a United States primary care population. Asian J. Androl. 2014; 16(6): 858–863. PubMed Abstract | Publisher Full Text | Free Full Text

[16] 16. Abolfotouh MA, Alabdrabalnabi AA, Albacker RB, et al.: Knowledge, attitude, and practices of infertility among Saudi couples. Int. J. Gen. Med. 2013; 6: 563–573. PubMed Abstract | Publisher Full Text | Free Full Text

[17] 17. Harris ID, Fronczak C, Roth L, et al.: Fertility and the aging male. Rev. Urol. 2011; 13(4): e184–e190.

[18] 18. George K, Kamath MS: Fertility and age. J. Hum. Reprod. Sci. 2010; 3(3): 121–123. PubMed Abstract | Publisher Full Text | Free Full Text

[19] 19. Kesehatan K, Riset L: Basic Health Research Report (Riskesdas) 2018. Jakarta: Badan Litbangkes, Kemenkes RI; 2019. Reference Source

[20] 20. Sugiharto E: Tingkat kesejahteraan masyarakat nelayan desa benua baru ilir berdasarkan indikator badan pusat statistik. [The Welfare Level of Fishermen Communities in Benua Baru Ilir Village Based on Indicators from the Central Bureau of Statistics]. EPP. 2007; 4(2): 32–36. Reference Source

[21] 21. Feleke BT, Wale MZ, Yirsaw MT: Knowledge, attitude and preventive practice towards COVID-19 and associated factors among outpatient service visitors at Debre Markos compressive specialized hospital, north-west Ethiopia, 2020. PLoS One. 2021; 16(7): e0251708. PubMed Abstract | Publisher Full Text | Free Full Text

[22] 22. Rea LM, Parker RA: Designing and conducting survey research: a comprehensive guide. 2nd ed.Hoboken, New Jersey: Jossey-Bass; 1992.

[23] 23. Boadi-Kusi SB, Holdbrook S, Kyei S, et al.: Knowledge, Attitudes and Practices of Postnatal Mothers on Ophthalmia Neonatorum in the Central Region, Ghana. Health Serv. Insights. 2021; 14:11786329211033248. PubMed Abstract | Publisher Full Text | Free Full Text

[24] 24. Koni A, Taha S, Daifallah A, et al.: A cross-sectional evaluation of knowledge, attitudes, practices, and perceived challenges among Palestinian pharmacists regarding COVID-19. SAGE Open Medicine. 2022; 10:20503121211069278. PubMed Abstract | Publisher Full Text | Free Full Text

[25] 25. Ashebir W, Yimer B, Alle A, et al.: Knowledge, attitude, practice, and factors associated with prevention practice towards COVID-19 among healthcare providers in Amhara region, northern Ethiopia: A multicenter cross-sectional study. PLOS Glob. Public Health. 2022; 2(4):e0000171. PubMed Abstract | Publisher Full Text | Free Full Text

[26] 26. Bennett LR, Wiweko B, Bell L, et al.: Reproductive knowledge and patient education needs among Indonesian women infertility patients attending three fertility clinics. Patient Educ. Couns. 2015; 98(3): 364–369. PubMed Abstract | Publisher Full Text

[27] 27. Carlsen E, Giwercman A, Keiding N, et al.: Evidence for decreasing quality of semen during past 50 years. BMJ (Clinical research ed.). 1992; 305(6854): 609–613. PubMed Abstract | Publisher Full Text | Free Full Text

[28] 28. Swan SH, Elkin EP, Fenster L: The question of declining sperm density revisited: an analysis of 101 studies published 1934-1996. Environ. Health Perspect. 2000; 108(10): 961–966. PubMed Abstract | Publisher Full Text | Free Full Text

[29] 29. Jørgensen N, Vierula M, Jacobsen R, et al.: Recent adverse trends in semen quality and testis cancer incidence among Finnish men. Int. J. Androl. 2011; 34(4 Pt 2): e37–e48. PubMed Abstract | Publisher Full Text | Free Full Text

[30] 30. Feki NC, Abid N, Rebai A, et al.: Semen quality decline among men in infertile relationships: experience over 12 years in the South of Tunisia. J. Androl. 2009; 30(5): 541–547. PubMed Abstract | Publisher Full Text

[31] 31. Fido A: Emotional distress in infertile women in Kuwait. Int. J. Fertil. Womens Med. 2004; 49(1): 24–28. PubMed Abstract

[32] 32. Schlegel PN, Sigman M, Collura B, et al.: Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline Part I. J. Urol.2021;205(1):36–43. Publisher Full Text PubMed Abstract |

[33] 33. Mehta A, Nangia AK, Dupree JM, et al.: Limitations and barriers in access to care for male factor infertility. Fertil. Steril.2016;105(5):1128–1137. Publisher Full Text PubMed Abstract |

[34] 34. Konsil Kedokteran Indonesia: Persebaran Dokter Berdasarkan Alamat Korespondensi [Geographical Distribution of Doctors by Correspondence Address]. 2022; Jakarta: KKI.

[35] 35. Daumler D, Chan P, Lo KC, et al.: Men’s knowledge of their own fertility: a population-based survey examining the awareness of factors that are associated with male infertility. Hum. Reprod.2016;31(12):2781–2790.Publisher Full Text | PubMed Abstract | Free Full Text

[36] 36. Iktidar MA, Chowdhury S, Roy S, et al.: Knowledge, attitude and perception among medical students and healthcare professionals regarding male infertility: a cross-sectional survey from Bangladesh. BMJ Open. 2022; 12(11):e062251. PubMed Abstract | Publisher Full Text | Free Full Text

[37] 37. Pemerintah Indonesia: Peraturan Pernerintah Republik Indonesia Nomor 61 Tahun 2014 tentang Kesehatan Reproduksi [Government Regulation of the Republic of Indonesia Number 61 of 2014 on Reproductive Health].2014. Reference Source

[38] 38. Menteri Kesehatan Republik Indonesia: Peraturan Menteri Kesehatan Republik Indonesia Nomor 43 Tahun 2015 Tentang Penyelenggaraan Pelayanan Reproduksi dengan Bantuan atau Kehamilan di Luar Cara Alamiah. [Regulation of the Minister of Health of the Republic of Indonesia Number 43 of 2015 on the Implementation of Assisted Reproductive Services or Pregnancy by Non-Natural Means].2015.Reference Source

[39] 39. BPJS Kesehatan: Panduan layanan bagi peserta BPJS kesehatan [Service Guidelines for BPJS Health Participants]. 2020; Jakarta: BPJS Kesehatan. Reference Source

[40] 40. Swift BE, Liu KE: The effect of age, ethnicity, and level of education on fertility awareness and duration of infertility. J. Obstet. Gynaecol. Can. 2014; 36(11): 990–996. Publisher Full Text

[41] 41. De Jonge CJ, Gellatly SA, Vazquez-Levin MH, et al.: Male Attitudes towards Infertility: Results from a Global Questionnaire. World J. Mens Health.2023;41(1):204–214. Publisher Full Text | PubMed Abstract | Free Full Text

[42] 42. Eisenberg ML, Lathi RB, Baker VL, et al.: Frequency of the Male Infertility Evaluation: Data from the National Survey of Family Growth. J. Urol.2013;189(3):1030–1034.Publisher Full Text PubMed Abstract |

[43] 43. Chandra A, Copen CE, Stephen EH: Infertility service use in the United States: data from the National Survey of Family Growth, 1982-2010. Natl. Health Stat. Report.2014; 73:1–21.

[44] 44. Sharifi F, Jamali J, Larki M, et al.: Domestic violence against infertile women: a systematic review and meta-analysis. Sultan Qaboos Univ. Med. J. 2022; 22(1): 14–27. PubMed Abstract | Publisher Full Text | Free Full Text

[45] 45. American Urological Association: Practicing urologist in the United States 2022 . 2023; Maryland: AUA.

[46] 46. Ofasu-Budu D, Hänninen V: Ways of reducing the stigma of infertility: views of infertile women and their herbalists. Afr. J. Reprod. Health. 2021; 25(2): 110. Publisher Full Text

[47] 47. Aljassim N, Ostini R: Health literacy in rural and urban populations: a systematic review. Patient Educ. Couns. 2020; 103(10): 2142–2154. PubMed Abstract | Publisher Full Text

[48] 48. Almeida-Santos T, Melo C, Macedo A, et al.: Are women and men well informed about fertility? childbearing intentions, fertility knowledge and information-gathering sources in Portugal. Reprod. Health. 2017; 14(1): 91. PubMed Abstract | Publisher Full Text | Free Full Text

[49] 49. McLernon DJ, Steyerberg EW, Velde ER, et al.: Predicting the chances of a live birth after one or more complete cycles of in vitro fertilisation: population based study of linked cycle data from 113 873 women. BMJ. 2016; 355(i5735):27852632. PubMed Abstract | Publisher Full Text | Free Full Text

[50] 50. Direktorat Statistik Kependudukan dan Ketenagakerjaan: Booklet Survei Angkatan Kerja Nasional Agustus 2022 [Booklet of the August 2022 National Labor Force Survey]. 2022; Jakarta: Badan Pusat Statistik.

[51] 51. Valsangkar S, Bodhare T, Bele S, et al.: An evaluation of the effect of infertility on marital, sexual satisfaction indices and health-related quality of life in women. J. Hum. Reprod. Sci. 2011; 4(2): 80–85. PubMed Abstract | Publisher Full Text | Free Full Text

[52] 52. Nyarko SH, Amu H: Self-reported effects of infertility on marital relationships among fertility clients at a public health facility in Accra, Ghana. Fertil. Res. Pract. 2015; 1: 10. PubMed Abstract | Publisher Full Text | Free Full Text

[53] 53. Hawkins AJ, Willoughby BJ, Doherty WJ: Reasons for divorce and openness to marital reconciliation. J. Divorce Remarriage. 2012; 53(6): 453–463. Publisher Full Text

[54] 54. Welz AN, Emberger-Klein A, Menrad K: Why people use herbal medicine: insights from a focus-group study in Germany. BMC Complement. Altern. Med. 2018; 18(1): 92. PubMed Abstract | Publisher Full Text | Free Full Text

[55] 55. Akbaribazm M, Goodarzi N, Rahimi M: Female infertility and herbal medicine: an overview of the new findings. Food Sci. Nutr. 2021; 9(10): 5869–5882. PubMed Abstract | Publisher Full Text | Free Full Text

[56] 56. Kashani L, Akhondzadeh S: Female infertility and herbal medicine. J. Med. Plants. 2017; 16(61): 3–7.

[57] 57. Anh NH, Kim SJ, Long NP, et al.: Ginger on human health: A comprehensive systematic review of 109 randomized controlled trials. Nutrients. 2020; 12(1): 157. PubMed Abstract | Publisher Full Text | Free Full Text

[58] 58. Ahmad S, Campos MG, Fratini F, et al.: New insights into the biological and pharmaceutical properties of royal jelly. Int. J. Mol. Sci. 2020; 21(2): 382. PubMed Abstract | Publisher Full Text | Free Full Text

[59] 59. Suleiman JB, Bakar ABA, Mohamed M: Review on bee products as potential protective and therapeutic agents in male reproductive impairment. Molecules. 2021; 26(11): 3421. PubMed Abstract | Publisher Full Text | Free Full Text

[60] 60. Pedro J, Brandão T, Schmidt L, et al.: What do people know about fertility? a systematic review on fertility awareness and its associated factors. Ups. J. Med. Sci. 2018; 123(2): 71–81. PubMed Abstract | Publisher Full Text | Free Full Text

[61] 61. Ahmadi H, Montaser-Kouhsari L, Nowroozi MR, et al.: Male infertility and depression: a neglected problem in the Middle East. J. Sex. Med. 2011; 8(3): 824–830. PubMed Abstract | Publisher Full Text

[62] 62. Fisher JR, Hammarberg K: Psychological and social aspects of infertility in men: an overview of the evidence and implications for psychologically informed clinical care and future research. Asian J. Androl. 2012; 14(1): 121–129. PubMed Abstract | Publisher Full Text | Free Full Text

[63] 63. Birowo P, Mushlih Y, Adli, et al.: Knowledge, Attitudes, and Practices Regarding Male Infertility; A Cross-Sectional Study Among Infertile Couples Visiting Fertility Clinics in Indonesia’s Urban Areas. [Dataset]. 2023, July 28. Publisher Full Text

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

Abstract

Keywords

Revised Amendments from Version 1

Introduction

Methods

Ethical considerations

Study design and sampling

Measurement tool and data management

Data analysis

Results

Sociodemographic data

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

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

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

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

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

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

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

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

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

Discussion

Conclusion

Data availability

Underlying data

Extended data

References

Comments on this article Comments (0)

Open Peer Review

Comments on this article Comments (0)

Open Peer Review

Reviewer Status

Reviewer Reports

Comments on this article

Browse by related subjects

Competing Interests Policy

Stay Updated