Exploring Infertility in Saudi Arabia: Qualitative Insights into IVF Treatment Services and Policy Recommendations

Introduction

Infertility is increasingly recognized as a pressing public health concern affecting millions of individuals and couples worldwide. According to the World Health Organization (WHO), approximately 17.5% of adults experience infertility.¹ Fertility rates in the Middle East and North Africa have fallen since the 1960s, dropping from an average of seven births per woman to 2.6 in 2021.² Furthermore, fertility rates in Saudi Arabia have steadily decreased, from 7.6 births per woman in 1960 to 2.46 births per woman in 2020. This surge has led to the global adoption of in vitro fertilization (IVF), which has significantly increased over the last 40 years. Since the first successful IVF birth in 1978, over eight million children have been born using this method.³

IVF treatment was introduced in the Middle East during the 1980s, starting in Saudi Arabia. Currently, more than 35 centers in the Kingdom of Saudi Arabia (KSA) conduct approximately 20,000 IVF treatment cycles annually, with the majority of these facilities operating within the private sector.⁴ The number of centers offering these services varies significantly by region in the Kingdom. In the Eastern Province, there is only one government center and four private centers that provide IVF services.⁵

Despite this remarkable growth, various economic, social, cultural, and structural barriers prevent many individuals struggling with infertility from accessing IVF treatment.³ The existing literature on perceptions of these services and the factors affecting accessibility in Saudi Arabia is limited. Nevertheless, global studies have shed light on patients’ perceptions and factors influencing their experiences with IVF treatment. For instance, a study conducted on the perceptions of infertility patients from six European countries found that factors such as a lack of knowledge of success rates, the high cost of treatment, and religious beliefs were obstacles to receiving those services.⁶ Additionally, studies have found other factors that limit the number of couples seeking infertility treatment, including societal, mental, and economic challenges.⁷

The most notable societal influence is the stigma surrounding male infertility, which can lead to a refusal of medical treatment, even when a male factor issue is suspected.⁹

The emotional aspects of infertility can prevent patients from pursuing treatment. Gibson and Myers emphasized the need for counselors to be aware of infertile women’s coping needs and specific interventions to help them cope effectively with infertility stress.¹⁰

This study aimed to examine the perceptions of patients with infertility regarding IVF services in the Eastern Province of Saudi Arabia. Additionally, we sought to identify factors that influence the process of seeking and receiving IVF treatment. The findings of this study will provide valuable insights for decision makers, enabling them to enhance the quality and accessibility of these services while fostering more culturally sensitive care. Furthermore, the results will inform the development of policies aimed at enhancing IVF services, ensuring that they are more effective and responsive to patient needs.

Methods

This study employed a descriptive phenomenological qualitative method, specifically using a hybrid thematic analysis approach that incorporates both deductive and inductive coding. Initially, open coding was performed to organize the textual data and assign codes. This was followed by axial coding, which established the relationships between codes to create subcategories. Finally, selective coding is applied to connect these subcategories, ultimately leading to the development of overarching themes.^11,12

The researchers implemented a purposeful sampling technique to select relevant participants. The inclusion criteria specified that the target population consisted of couples seeking IVF treatment in the Eastern Province of Saudi Arabia. Participants were categorized into three groups: patients, medical caregivers, and administrative staff at IVF centers. Those residing outside the Eastern Province were excluded because regional differences in healthcare delivery, culture, and available resources could significantly impact the findings. Furthermore, data collection and analysis were performed concurrently until data saturation was achieved with a sample of 15 participants. Data saturation refers to the stage in qualitative research in which additional data collection no longer generates new insights or themes.¹³

Data were collected through individual in-person interviews conducted in infertility clinics in Khobar and Dammam, Eastern Province, Saudi Arabia, except for one interview conducted by phone at the participant’s preference. Participants received consent forms that were read and signed before the interviews were conducted. As for the participants interviewed over the phone, verbal consent was obtained prior to the interview. The interviews ranged from 45 minutes to two hours.

To improve the accuracy and reliability of the data, this study used a triangulation method for data sources, aiming to foster a thorough understanding of the phenomena under investigation. Data triangulation involves the use of multiple participants to verify the information gathered, ensuring that the findings are not biased or limited to a single perspective. In this study, data were collected from three different groups of participants: patients with infertility, caregivers, and administrative staff working in infertility clinics. In addition, data were collected from five hospitals. Two of the hospitals were government-run, and three were private.¹²

Finally, the interview recordings were transcribed, and analyzed using ATLAS.ti after obtaining a copyright license. The analysis involved applying the necessary codes and themes. The study spanned six months, beginning with data collection in November 2023.

Results

Of the 15 participants, five were OBGYN and infertility specialists, seven were patients, and three were administrative staff. Among the seven patients, five were female and two were male, with ages ranging from 19 to 46 years, all of whom were located in Khobar, Eastern Province. Their occupations vary, and include students, nurses, and some who are unemployed. The five medical caregivers consisted of obstetricians, reproductive medicine consultants, and a senior infertility consultant distributed between Khobar and Dammam. Lastly, the three administrative staff members worked as infertility clinic coordinators and nursing consultants, with two based in Khobar and one in Dammam [ Table 1].

Discussion

This study aimed to discover participants’ attitudes towards infertility and IVF-related services, and to explore the barriers to seeking treatment. Key findings highlight that infertility is perceived to be on the rise, with a significant emphasis on male factor infertility as a prevalent issue. Participants reported barriers to accessing infertility services, including financial burden, lack of awareness, societal influences, and lengthy, complex treatment processes. The limited availability of government resources and the absence of insurance coverage for infertility treatments further exacerbate these challenges.

One notable finding was that patients expressed that a major obstacle is the length and complexity of the IVF treatment process, especially when most couples go through more than one cycle before success. A study conducted in the UK on live birth rates associated with repeated IVF cycles supported this finding, finding that three out of 10 women succeeded with their first cycle of IVF, while seven out of 10 succeeded by their sixth cycle.¹⁴

In this study, the financial burden was another commonly cited barrier. This result aligns with that of a qualitative research conducted by Mosalanejad et al., who stated that treatment cost is the greatest barrier, even for people with high incomes.⁸ Similarly, Insogna et al. mentioned that cost was reported as a barrier to care by 62.8% of the respondents.¹⁵

The patients also expressed that they felt that they were not properly guided or informed. This prevented them from seeking treatment, either because they lacked knowledge of their condition or when to take the next step, which could lead to discontinuation of treatment, which aligns with the findings of Mosalanejad et al.⁸

Another factor shared by participants was that one governmental center offering infertility treatment in the Eastern Province was not sufficient. This obstacle was also supported by Fahimi et al., and Mosalanejad et al. also mentioned the lack of infertility centers as a barrier.^8,16

Another obstacle reported by several participants was the stigma surrounding infertility and its societal influence. Patients shared experiencing pressure from their families to conceive and fear disappointing them if the treatment failed. Cultural stigma surrounding male infertility has also been noted. Traditionally, women were seen as responsible for infertility, and men were hesitant to get tested due to fear of judgment, stigma, or damage to their masculinity. Agarwal et al. also recognized this issue and suggested increasing awareness and encouraging society to reduce barriers to infertility stigmas rooted in cultural beliefs.¹⁷

The lack of sufficient health insurance coverage does not include infertility treatment. Therefore, these procedures can be costly for patients, especially for IVF, which creates a barrier to treatment. The participants mentioned that insurance should cover infertility treatment because infertility is a medical condition similar to any other condition. This finding was supported by Jain et al. and Peipert et al., who concluded that comprehensive mandated insurance coverage increased the utilization of these services, but decreased multiple birth rates.^18,19 This factor was also supported by Al-Turki, who noted that a limited number of government hospitals in the Eastern Province offered IVF. The demand for more government infertility centers is clearly high due to the lack of insurance coverage and the number of patients who cannot afford to pay out-of-pocket for treatment in the private sector.⁵

One limitation of this study was the lack of current infertility statistics in Saudi Arabia. Owing to the sensitive nature of the research topic, it was challenging to find patients, particularly men, who were willing to share their experiences. As a result, most participants were women, which limits the male perspective in this study. Additionally, information about the private sector is not publicly available, and staff at private clinics are hesitant to be interviewed or share how they manage their infertility clinics and patients. This may have affected the study’s results by limiting insights into private clinic administrative perspectives and emphasizing those of government hospitals.

Conclusions

This study examines public perceptions and attitudes toward IVF-related services to identify the barriers encountered when seeking treatment. These findings reveal a growing concern regarding infertility, particularly highlighting male factor infertility as a significant issue. Participants identified several obstacles to accessing infertility services, including financial constraints, insufficient awareness, societal pressures, and the lengthy and complicated nature of the treatment processes.

Additionally, the limited availability of government resources and lack of insurance coverage for infertility treatments further intensify these challenges. Patients without insurance coverage should be able to receive treatment at government clinics. Moreover, there should be sufficient government clinics to accommodate patients who cannot afford treatment and who lack insurance coverage.²⁰

Owing to the challenges encountered when interviewing administrative staff in private infertility clinics, there should be greater transparency of information, especially with researchers. This will help provide a comprehensive understanding of infertility services available in both the government and private sectors. Access to data can support further research on infertility and improve current infertility services by offering information and insights to decision makers. Dyer and Zegers-Hochschild highlighted the potential impact of registries on reproductive health. By utilizing registry data, individual centers and countries can benchmark their performance against national, regional, and global standards, thereby providing valuable insights for research. This aligns with the findings of Abduljabbar and Amin, who noted that Saudi Arabia could enhance its international contributions to Assisted Reproductive Technology practices by establishing a government-managed IVF registry, thereby facilitating the global exchange of information.²¹

Finally, to address one of the patients’ main concerns, navigating the complex and lengthy process of infertility treatment, we propose the use of case management. This policy recommendation can lead to the development of a systematic method in which a specialized professional, typically a nurse or care coordinator, assists patients in navigating intricate IVF procedures. Furthermore, research has demonstrated that this approach can enhance patient satisfaction. It also has the potential to alleviate anxiety and depression in individuals who have experienced pregnancy loss following in vitro fertilization and embryo transfer. Implementing such a policy in Saudi hospitals could streamline the process and positively impact patients’ mental health and overall quality of life.²²

Ethics and consent

Ethical approval in accordance with the Declaration of Helsinki was obtained from the Institutional Review Board of Imam Abdulrahman Bin Faisal University. The IRB number was IRB-PGS-2023-03-259. All participants’ information and interviews were handled with strict confidentiality. Before the interviews began, the participants signed consent forms to confirm their approval to participate.