Infertility is defined as a disease of the reproductive system characterised by the failure to achieve clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (1). Recent estimates show that infertility is a common global public health problem, affecting one in six people of reproductive age (2). In addition, prevalence of infertility does not differ significantly between high-income and low- and middle-income countries, demonstrating that it affects people everywhere (2).

Infertility has significant biomedical implications, and can affect physical, emotional and social wellbeing (3). For couples who decide to start a family, difficulty conceiving a child can become a source of tension, conflict (4), financial stress (5), and ultimately poor quality of life (6). Indeed, in most countries, infertility has consequences for families and communities, through its effects on stigma, domestic violence, divorce, polygamy and even suicidal thoughts (7–10).While men often contribute to infertility in a couple, women are often blamed (8, 9), and are often disproportionately stigmatized, disinherited or neglected within families and communities (8–10).

The experiences, financial and social consequences of infertility could differ between countries and cultures (9).However, there is consensus that in all settings, the initial diagnosis of infertility has a profound negative impact on both men and women (3). Additional stress can occur during treatment of infertility (6, 11), and contribute to interruption of care and further delay there solution of infertility (12). Indeed, assisted reproductive technologies (ART) are a source of significant psychological consequences (13).Therefore, holistic understanding of the experience of infertility from diagnosis, through to treatment is important.

In Morocco, infertility is estimated to affect12% of couples, according to a 2015 nationwide survey (14). A recent study showed that 39.6% of infertility cases were due to a female factor, 28.2% had a male factor, 17% had both male and female factors and in 15.2% of couples, the cause of infertility was undetermined (15). Despite this burden of infertility, provision of in vitro fertilization (IVF) and other medically assisted reproduction services has not historically been a policy priority (16), as is the case in many other low and middle income countries (17). In recent years however, Moroccan national health sector policies have started to address infertility, with a recent commitment to establish a “National plan for ART” (18), that lead to the development of the first public ART center in Morocco in 2013 (19).

While there is ample evidence that infertility is common in Morocco, little is known about the experiences of infertility among infertile couples in the country. Isolated studies indicate that infertile couples suffer from depression, anxiety (20) and stress (21), while another study found that infertile Moroccan couples are in need of information as well as social, spiritual, emotional and financial support during the infertility treatment (22). Apart from these studies, little other documentation exists in relation to experiences of people with infertility in Morocco.

Findings showed varied experiences which include (i) biomedical experiences (ii) gendered social experiences (iii) psychological experiences as well as (iv) financial experiences as shown in the following Table 3.

This paper reports the experiences of couples with infertility in Morocco, which is rarely researched in the country. Results provide rich insights showing a wide range of experiences among the participating couples. Several hallmark features of couples' experiences were identified that warrant further discussion.

First, there was an information and orientation problem, which was associated with a lack of a clear infertility care pathway, diagnostic delay, and lack of information regarding treatment plan. Patients were not involved nor informed what their treatment journey would entail. Research from other countries indicates that there is a lack of adequate information and preparation of patients so that they would know what the diagnosis and treatment entails. This is a significant part of patients' experiences of infertility (25), and while numerous studies indicate that patients desire to be informed about their planned treatment (26), health providers do not always involve them in such discussions (27).

These findings suggest that patients should be counselled, informed, and discussed with, regarding their treatment journey. It is important to clearly inform patients what the therapeutic management is so that they can know what the first option, second option or other advanced options are. Although Morocco has national guidelines (a national guide for the management of infertile couple was developed in 2016), it is unclear if these are followed by all stakeholders, including all gynecologists in both the public and private sectors. It would be important to sensitize health professionals about the national guidelines and insist that they communicate with patients about what the diagnostic and treatment strategy would be expected to be, based on these guidelines. Fundamentally, it is important to raise awareness among health professionals about the importance of information and communication with infertile couples.

Second, our study shows that there was lack of continuity of care and multiplicity of treatments. Repetition of treatments and procedures has been reported in other settings, but in our study setting, this was particularly driven by frequent change of doctors among participating patients who were frustrated or seeking second opinion, as well as drop off from treatment due to financial problems. While many of the participants interviewed in our study were accessing fertility care, unfortunately, in many low- and middle-income countries as shown in studies conducted in the Gambia (28), Kenya (29), South Africa (30),, Zambia (31) and other countries access to infertility services, including specialized interventions such as IVF, is very limited, and it can be anticipated that access to care could also be fragmented in those countries. This is particularly relevant given that IVF is expensive and unaffordable in many low income settings (5), which also prevents its inclusion in public policies and services (4, 32).Yet financial costs have been shown to contribute to stressful infertility experiences (33). These findings suggest that enhancing financial protection through inclusion of infertility treatment in health insurance schemes, or reimbursements of costs would improve patients' experiences and enhance continuity of treatment.

Third, the use of traditional therapies such as herbal therapy, bloodletting, witchcraft, and religious blessings was identified as a contributor to some negative experiences, for example gastrointestinal side effects. Given that some of these were driven by desperation, there is a need for tactful messages to couples to lessen psychological impact in case of poor prognosis, while at the same time educating patients about the potential risks of use of some traditional therapies. Use of traditional or folk therapies has also been reported in other low income (34, 35) rarely, in high income (36) settings, often because they are cheaper compared to modern medicine. In our setting, it is not clear whether the risks of some of the folk therapies were known to participants. This points to the need for IEC (Information—Education—Communication), for example organized information campaigns in basic health care facility in order to enhance awareness among couples on the potential danger of traditional therapies. Health professionals should devote some time during their daily practice to counseling about these practices.

A surprising finding was that patients had mixed experiences with the private sector, which was partly related to financial implications of treatment. While nearly all the participants had attended a private practice previously, there was tension in that private sector, doctors were sought for their expertise, yet there was a problem of trust with private practices in general. There was a perception that private doctors may recommend expensive treatments when not needed. This is consistent with reports from other countries where private sector is perceived as driven by economic motivations (28, 37, 38). Yet, the private sector is an important part of the health system in Morocco, and it is important that all practitioners follow the guidelines, standard operating procedures.

Fourth, negative psychosocial experiences, which are often gendered were common part of the couple in this study, including stigma and discrimination, isolation, as well as marital and relationship difficulties, which disproportionately affected women. Numerous other studies have shown the gendered way in which infertility is experienced, which is consistent to our findings (39). Besides this gendered experience, overall, a good number of participants in our study reported a variety of emotional and psychological distress experiences, including depression, anxiety, anger. Similar findings have been demonstrated in other countries showing widespread experiences of negative social pressures (8), and relationship problems (40) as well as emotional psychological distress among patients with infertility (40–42), which are often linked to widespread stigmatization of infertility in communities, for example in Malawi (43), Zambia (31), Bangladesh (44) and numerous other countries. In our study, and in attempts to cope with the societal pressures and stigma, participants sought to keep their treatment a secret, which was itself an additional psychological burden, a finding that supports previous assertions that treatment itself can be an important source of distressing psychological experience (6, 40).

This finding suggests that there is the need to destigmatize infertility in Moroccan communities. There is a role for using media channels (TV, Radio, social media) to enhance the understanding of infertility and destigmatize it. IEC is needed to ensure that communities understand that infertility is a preventable and treatable condition. A lack of information on infertility is rampant in many counties, and researchers have identified the need for awareness raising campaigns to destigmatize infertility (45) and assist in help seeking (46). Apart from destigmatizing it, efforts are needed to strengthen psychological support as part of the management of infertile couples. Social and psychological support is not included in the national guidelines, and therefore needs to be strengthened in the future. An important practical step would be to ensure that the national guidelines are expended to include a psychosocial section.

In addition, to operationalizing psychosocial support, it would be important to ensure that a psychologist is included as part of the team of every fertility center. Where this is not feasible, focal health care providers should be trained on psychological counselling. Studies from other countries have shown that this is an important part of management that could reduce psychological, relational and social impact of infertility (40), including gendered-stigma (39). Another practical step that can be implemented is the creation of patient support groups which can provide members with a sense of empowerment, help sharing coping strategies, provide a sense of community. This is particularly important given that many participants felt lonely and isolated, and relied on social support from families, spouses, or friends, which was not always structured or forthcoming. Studies suggest that it is often difficult to create support groups for stigmatized conditions, but where these exist, they enhance the capacity of members to resist or cope with their diagnosis (40). Based on the findings of a recent review of effective psychosocial interventions (39), these kinds of interventions will require to be tailored to cultural norms of the targeted settings, for example ensuring that the gendered experiences target reshaping of masculinities.

In addition, our findings suggest the centralized nature of IVF treatment creates both financial and disruption of social lives of participants. A potential solution to this issue is the creation of centers in several regions of the country. At present there are only 3 Public ART centers, which serve the entire country as referral centers. A practical way of decentralizing these services is the creation of an ART center in every University Hospital meaning one for each region. This will ensure the training of health professionals on ART in decentralized centers and that patients will not have to travel as far as they do now. Indeed, as shown in Table 5, a range of implications for policy and practice could be considered.

Finally, many of the experiences of our participants are interconnected, and these interconnections spanned by individual, interpersonal, social and structural domains. One the one hand, the social and gendered distinction between both partners caused emotional distress among women, could trigger marital and relationship difficulties, and exacerbate psychological suffering. On the other hand, psychological suffering often occurred due to social isolation, but was also linked to lack of sufficient information about treatments, the multiplicity of treatments or financial problems. Financial pressures often led to multiplicity of treatments, which was linked to linked to the disruption of care and the disturbance of professional lives, particularly because of the distances involved in accessing care (Figure 1). The financial problems and disrupted care affected couples emotional well-being leading to a feeling of helplessness and other psychological problems. The existence of gendered social pressure impacted the marital experiences of couples undergoing infertility treatments by amplifying their distress, both of which contributed to psychological suffering. These experiences overlap in their influences, and often intensify the overall experience of couples seeking infertility treatments as shown in Figure 1. Our finding of interconnectedness of these influences is consistent with a recent study demonstrating intersecting drivers of experiences of infertility among women in India (47), and implies the need for a holistic approach when addressing all the issues faced by the couples during their treatment journey (Table 5).

This study is not without limitations, the main one is limited generalizability. Given that the study included a relatively small size sample recruited from a single Public ART Center and in the capital city, the results might not reflect on the experiences and perspectives of a larger population of infertile couples, it also might not show regional and cultural differences. However, the Center serves as a referral center for the country which could mitigate this limitation. Additionally, our primary intention was to show diverse and representational examples of experiences, through qualitative enquiry. Nevertheless, given that ours constituted a convenient sample, recruited consecutively based on their routine clinic appointments, it is possible that the research teams positionality, and the situatedness of the study could have influenced what participants diverged (23).

Although extensive thematic analysis was conducted through the aid of software, it is possible that some relevant themes may remain unidentified (23).Moreover, all the participants had sought treatment at the center which excludes all the infertile couples who did not want or could not seek treatment; therefore, our study excludes the possibility of themes, alternative experiences and complex or diverse viewpoints from those not accessing treatments. Nevertheless, our study provides useful learnings that may inform improvement of experiences of couples with infertility and may represent a basis for future research. In future, consideration of multicentre studies involving ART centres from various regions in Morocco, along with their varying health system and cultural contexts could provide additional learnings relate to experiences of infertility, by capturing a broader range of experiences and perspectives. Additional study designs that can be considered may include use of a longitudinal design which can provide information on experiences over time. Although our studies used interviews, the combination of interviews, focus groups, and observations may add more insight where these methods complement each other.

This paper reports the experiences of couples with infertility in Morocco, which is rarely researched in the country and other low- and middle-income settings. Results provide rich insights showing the wide range of experiences that couples with infertility go through, which include biomedical experiences (diagnostic delays, fractured care, multiplicity of treatments), gendered social experiences (gendered social pressures, stigma, discrimination, isolation and disrupted social routines) psychological experiences (anger, anxiety, depression, and mood changes) as well as financial experiences (out of pocket payments and financial indebtedness). The results of this research indicate the urgent need for a wide range of health systems strengthening strategies to improve the experiences of people with infertility, including the financial protection, service decentralization, public education campaigns to educate the public and destigmatize infertility, social support groups for people with infertility, and enhanced psychological counselling as part of routine fertility care provided to infertile couples. Given interconnectedness between biomedical, social, psychological, and financial divers of experiences, a holistic approach is required to comprehensively improve the situation of infertile couples.