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.

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.’s ⁴⁸ 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 review ⁶⁰ 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.

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.