Epidemiology of infertility and coping mechanisms in Ethiopia, 2025: a systematic review and meta-analysis.

After a comprehensive search for articles as per the predefined inclusion criteria, 11 studies were ultimately included. Among the included studies, five studies assessed the prevalence of primary, secondary or both types of infertility, whereas six studies discussed the different coping mechanisms applied. The final 11 studies consisted of a total of 24,052 study participants reporting the prevalence of infertility and 84 participants reporting coping mechanisms. The search findings are presented via the updated PRISMA 2020 flow diagram [ 24 ] in Fig.  1 . We used the Newcastle‒Ottawa Scale (NOS) adapted for cross-sectional studies [ 25 ] for quality assessment, as described in the methodology section. Only one study was conducted with men [ 30 ]; the others involved women or couples. Three studies were conducted at hospitals in Addis Ababa [ 30 – 32 ], and two studies analyzed the national EDHS [ 10 , 33 ]. The data collection method was an interview with a structured questionnaire in 3 studies [ 30 – 32 ], one study analyzed the 2005 Ethiopian demographic and health survey (EDHS 2005) [ 33 ], and one study analyzed the EDHS 2016 [ 10 ] (Table  1 ). Table 1 Description of the studies included to assess the prevalence of infertility in ethiopia, 2025 Authors (Years), Ref. Number Design Study Place Sample Size Population Data collection Method Type of infertility Prevalence (%) Araya et al., 2024 [ 10 ] CS National 15,683 Women (20–49 years) Analyze 2016 EDHS Overall (both) 7.6% ( 6.6–8.8 ) Primary = 1.4 (95% CI: 1-1.9) secondary = 8.7 (7.5–10.1) Tsegazeab , 2021 [ 30 ] CS Addis Ababa 354 Men Structured questionnaire Overall 62.4% Primary 52.8%, Secondary 9.6% Akalewold et al. , 2022 [ 31 ] Cross-sectional (CS) Addis Ababa 441 Women (15–49 years) Interview with a structured questionnaire Overall/primary and secondary 27.6% (95% CI = 23.2–32.0) Primary (14.4) secondary (13.2) Abtew , 2024 [ 32 ] CS Adis Ababa 355 Women (15–49 years) interviewer-administered questionnaire Secondary 33.2% (Haddis et al., 2010 [ 33 ] CS National 7219 Women (15–49 years) Analyses of 2005 EDHS Secondary 4.6% Description of the studies included to assess the prevalence of infertility in ethiopia, 2025 Araya et al., 2024 [ 10 ] 7.6% ( 6.6–8.8 ) Primary = 1.4 (95% CI: 1-1.9) secondary = 8.7 (7.5–10.1) Tsegazeab , 2021 [ 30 ] 62.4% Primary 52.8%, Secondary 9.6% Akalewold et al. , 2022 [ 31 ] Women (15–49 years) 27.6% (95% CI = 23.2–32.0) Primary (14.4) secondary (13.2) Abtew , 2024 [ 32 ] (Haddis et al., 2010 [ 33 ] Among the five quantitative studies, four articles were identified with a score of high quality (7–10), and the remaining article was found to be between 5 and 6 and was deemed average quality by using the NOS (Table  2 ). Table 2 Modified newcastle‒ottawa scale adapted for cross-sectional studies to assess quality of studies, 2025 Reference No, Author (Years) Criteria Selection (5*) Comparability (2*) Outcome (3*) 10* Representativeness of the sample Sample size Nonresponse rate Ascertainment of exposure Study controls for the most important factor Control for any additional factor Assessment of the outcome Statistical test Quality score Araya et al., 2024 [ 10 ] * * * ** * * ** * 10 * segazeab,2021 [ 30 ] * * * * * * 6 * Akalewold et al. 2022 [ 31 ] * * * ** * * * * 9 * Abtew, 2024 [ 32 ] * * * * * * * 7 * Haddis et al., 2010 [ 33 ] * * * ** * ** * 9 * Keywords: *=1 Point and **=2 Points Modified newcastle‒ottawa scale adapted for cross-sectional studies to assess quality of studies, 2025 Keywords: *=1 Point and **=2 Points All the incorporated quantitative studies were published from 2010 [ 33 ] to 2024 [ 10 ]. A total of five studies assessed the prevalence of infertility, three studies were conducted on both primary and secondary infertility, with the overall prevalence reported, and two studies investigated only secondary infertility [ 32 , 33 ]. As shown in Table  1 above, the prevalence of infertility ranged from 4.6% in women [ 33 ] to 62.4% in men [ 30 ]. One study reported the overall prevalence of infertility to be 7.6% according to the demographic definition and 24.1% at 12 months, 13.4% at 24 months and 8.8% at 36 months according to the current definition [ 10 ]. Initially, a forest plot was generated for the primary outcome (prevalence) via the fixed effect model, and heterogeneity was identified. We assessed the differences in the reported prevalence of infertility between the studies via Cochran’s Q test and I² statistics. A p value of less than 0.05 from the Cochran’s Q test indicated statistical significance, with variation levels indicated by the I2 statistic ranging from 0% to 100%: 0%-no variation, 25%-minor variation, 50%-moderate variation, and >−75%, greater variation. Because of the heterogeneity observed in the studies, we applied a random effects model to the present meta-analysis. This provided a complete picture and understanding of the data being aggregated. The overall pooled prevalence of infertility determined via the random effects model was 25.77% [95% CI: 20.10, 31.45], with a heterogeneity index (I2 = 99.48, P  = 0.00), indicating substantial heterogeneity in the included studies (I2 > 75%) (Fig.  2 ). We also carried out Egger’s regression tests and assessed the funnel plot to estimate possible publication bias, which was confirmed. Fig. 2 Forest plot for the pooled prevalence of infertility in Ethiopia, 2025 Forest plot for the pooled prevalence of infertility in Ethiopia, 2025 When we performed the subgroup analysis for the prevalence of infertility by study location, the subgroup prevalence was highest in Addis Ababa, at 41.04% [20.34, 61.73], with I2 = 99.8, p  = 0.00, and lowest in national studies (EDHS analysis), at 6.103% [3.163–9.04], with I2 = 99.83, p  = 0.00 (Fig.  3 ). Fig. 3 Subgroup analysis of the prevalence of infertility by study area Subgroup analysis of the prevalence of infertility by study area In terms of the type of infertility, the subgroup estimated prevalence of primary infertility was 22.76% [−0.95–46.47], with heterogeneity I2 = 99.54, p  = 00, and that of secondary infertility was 12.67% [9.14–16.20], with I2 = 98.57, p  = 0.00. The overall pooled prevalence of primary and secondary infertility was 15.94 [12.28–19.60], with heterogeneity of I2 = 99.56 and p  = 0.00 (Fig.  4 ). This subgroup pooled prevalence was performed by drawing the prevalence of primary infertility from those studies that reported both primary and secondary infertility. This differed from the general pooled prevalence of 25.77% [95% CI: 20.10, 31.45] (Fig.  4 ). Fig. 4 Subgroup analysis of infertility prevalence by type of infertility Subgroup analysis of infertility prevalence by type of infertility The figure below shows the Galbraith plot of heterogeneity of the prevalence of infertility among included primary studies (Fig.  5 ). Fig. 5 Heterogeneity of studies on the prevalence of infertility Heterogeneity of studies on the prevalence of infertility Publication bias was assessed via graphical inspection of the funnel plot, and its presence was confirmed (Fig.  6 ). We also carried out Egger’s regression tests, and the publication bias was significant ( p  = 0.000). After one study with the highest prevalence of infertility [ 30 ] was removed, publication bias was not identified, and Egger’s regression test was not significant (Fig.  6 ). Fig. 6 Funnel plot for publication bias analysis Funnel plot for publication bias analysis The qualitative studies discussed the different coping mechanisms or strategies that infertile women, men or couples have used. The age of women ranges from 18 years [ 34 ] to 56 years [ 35 ]. Four studies were conducted in urban areas of the country [ 34 – 37 ], and two studies were conducted in rural areas [ 38 , 39 ]. The total sample size was 84 in all studies, ranging from 8 [ 36 ] to 20 [ 35 ]. Two studies were conducted on couples [ 35 , 38 ], 4 studies were conducted on women [ 34 , 36 , 37 , 39 ]. Five studies used a descriptive phenomenological design [ 35 – 39 ], and one study used an interpretive phenomenological design [ 34 ]. The data collection procedures applied were in-depth interviews (IDIs) and observations [ 36 ], IDIs [ 37 ], IDIs, focus group discussions (FGDs) and observations [ 35 ], only IDIs [ 38 ], semi-structured open-ended questions [ 34 ] and IDIs [ 39 ]. The coping mechanisms discussed were similar across all the studies. These activities included religious activities, seeking advice from friends; visiting health facilities [ 36 ]; religious coping; traditional/cultural, medical, and marital separation; acceptance of the case [ 37 ]; spiritual activities; traditional healers and medication [ 35 ]; spiritual treatment; engaging in extramarital relationships; medical treatment and fosterage (orphans preferred) [ 38 ]; faith, resilience, medical treatment; estranged and ostracized social life; helplessness; acceptance; hope [ 34 ]; and spiritual life; having a godchild (baptism of others’ child); seeking family and social support; adopting children in informal ways; and allowing a husband to bore from others [ 39 ] (Table  3 ). Table 3 Characteristics of the qualitative studies assessing coping mechanisms of infertility in Ethiopia 2025 Reference No, Authors (Years) Design Study Place Sample Size Population Data collection methods Outcomes (type of coping mechanism) Araya et al., 2025 [ 34 ] Interpretative phenomenology Urban/Addis Ababa 13 Women (>−18 years) Semi-structured open-ended questions Faith, resilience, medical treatment, estranged and ostracized social life, helplessness, acceptance, hope Mekonen, 2017 [ 35 ] Qualitative approach Urban 20 Couples (23–56 years) IDIs, FGDs, and Observation Spiritual, traditional healers and hospitals (biomedical) Meskelu &Berhane, 2018 [ 36 ] Qualitative approach Urban 8 Women (25 to 37 years) IDIs and Observations Religious activities, Advice from friends Visiting health facilities Adane et al.,2024b [ 37 ] Descriptive phenomenology Urban 15 Women IDIs Religious, Traditional/cultural Medical, Marital separation, and acceptance of the case Bayouh, 2011 [ 38 ] Qualitative approach Rural/South Gonder 19 Couples IDIs Spiritual treatment, Engaging in Extramarital relations, medical treatment, and Fosterage: (Orphans Preferred) Belete, 2018 [ 39 ] A qualitative approach with phenomenology design Rural/Meket Woreda 9 Women IDIs Spiritual life, having a Godchild (baptism of others’ child), Family and social support Adoption of children in informal ways and allowing for a husband to bore from others Characteristics of the qualitative studies assessing coping mechanisms of infertility in Ethiopia 2025 Women (>−18 years) Religious activities, Advice from friends Visiting health facilities Religious, Traditional/cultural Medical, Marital separation, and acceptance of the case Many tools are available to evaluate the quality of qualitative studies, however, we used the most widely used and appropriate tool, which is the JBI critical appraisal checklist for qualitative studies [ 26 ], and all studies scored a strong level (Table  4 ). Table 4 Joanna Briggs Institute (JBI) critical appraisal checklist for qualitative research, 2025 JBI Critical Appraisal Questions (10 items) Reference Number, Author (year) Araya et al., 2025, [ 34 ] Mekonnen, 2017, [ 35 ] Meskelu & Berhane, 2018, [ 36 ] Adane et al., 2024b, [ 37 ] Bayouh, 2011, [ 38 ] Belete, 2018, [ 39 ] Is there congruity between the stated philosophical perspective and the research methodology Yes Yes Yes Yes Yes Yes Is there congruity between the research methodology and the research question or objectives? Yes Yes Yes Yes Yes Yes Is there congruity between the research methodology and the methods used to collect data? Yes Yes Yes Yes Yes Yes Is there congruity between the research methodology and the representation and analysis of data? Yes Yes Yes Yes Yes Yes Is there congruity between the research methodology and the interpretation of results? Yes Yes Yes Yes Yes Yes Is there a statement locating the researcher culturally or theoretically? No No Yes No Yes No Is the influence of the researcher on the research, and vice-versa, addressed? Unclear Yes Unclear Yes Yes Yes Are participants, and their voices, adequately represented? Yes Yes Yes Yes Yes Yes Is the research ethical according to current criteria or, for recent studies, and is there evidence of ethical approval by an appropriate body? Yes Yes Yes Yes Yes Yes Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data? Yes Yes Yes Yes Yes Yes Overall Grade Strong (8) Strong (9) Strong (9) strong (9) Strong (10) Strong (9) Joanna Briggs Institute (JBI) critical appraisal checklist for qualitative research, 2025 Strong (9) Coping mechanisms were described as any behaviour, psychological, social, spiritual, or medical strategies that individuals or couples use to deal with the emotional, social, or physical effects of infertility. The synthesis of the current SRMA identified the following different specific coping mechanisms: religious life/activities, visiting health facilities for medical treatment, seeking advice from friends/family, traditional/cultural strategies, marital separation, acceptance of the case, engaging in extramarital relations, fostering, faith, hope and resilience, estranged and ostracized social life, helplessness, having a god child (baptism of others’ child) and adoption of children in informal ways. Overall, medical treatment and religious activities are the most common coping mechanisms. We sorted the above coping strategies into distinct themes: (i) seeking medical treatment, (ii) religious or spiritual practices, (iii) seeking social support, (iv) using traditional or cultural remedies, (v) acceptance or resignation, and (vi) avoidance or harmful behaviours. We used a thematic synthesis method to find common coping patterns across the studies, combining both qualitative and quantitative evidence. Because there were differences in how coping strategies were measured and reported, we did not conduct a pooled meta-analysis. Instead, we summarized the quantitative findings, like frequencies in a descriptive manner and presented the qualitative findings in a narrative form, emphasizing cultural and contextual differences. Most of the reported strategies were grouped under problem-focused coping mechanisms; however, estranged and ostracized social life and helplessness were identified in one study [ 34 ]. Religious coping/activity is the most commonly used form, and it was practical in all the studies. The second most common coping strategy reported in five out of six studies was seeking medical treatment [ 34 – 39 ]. The third most commonly used coping mechanism was the need for traditional or cultural healers, which was reported in two studies [ 35 , 37 ]. Support and advice from family or society [ 36 , 39 ]. In two studies, acceptance of the case (infertility) was also used as a coping method [ 34 , 37 ]. On the other hand, engaging in extramarital activity has been reported among infertile couples [ 38 , 39 ]. Having a God child (baptism of others’ child) was reported in one study [ 39 ].

The use of an evidence-based approach to practice requires “the integration of best research evidence with clinical expertise and patient values”, where the best evidence can be gathered from randomized controlled trials (RCTs) and systematic reviews and meta‐analyses (SRMA). The SRMA can provide the “best evidence” and an unbiased overview of the body of knowledge on a specific topic [ 23 ]. The objective of this review is to assess the prevalence and associated coping mechanisms of infertility in Ethiopia. This SRMA was conducted via the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA-2020). The structure and presentation of the items have been modified to facilitate implementation, an expanded checklist that details reporting recommendations for each item, the PRISMA 2020 abstract checklist, and the revised flow diagrams for original and updated reviews used [ 24 ]. This SRMA was conducted via the PRISMA 2020 guidelines [ 24 ] to investigate the epidemiology of infertility and its coping mechanisms among infertile Ethiopian women, men and/or couples. We searched all noninterventional studies electronically in CINAHL, EMBASE, PubMed/MEDLINE, the Cochrane Library, Scopus, Web of Science and Google Scholar. The references of the retrieved studies were also searched for further articles. Additionally, a manual search for a thesis/dissertation was carried out on university websites. The search was performed under the PEO framework between March 5 and February 14, 2025. Population: women and men; Exposure: infertility; Outcome: coping mechanisms/strategies for infertility. Studies reporting the prevalence and/or coping mechanisms of infertility in Ethiopia were included. The principal aim of this review was to assess the epidemiology of infertility and coping mechanisms in Ethiopia. In this systematic review and meta-analysis, a systematic evaluation of the included studies concerning infertility was conducted. We checked the PROSPERO database ( https://www.crd.york.ac.uk/prospero/ ) to determine whether there are any recently published, completed or ongoing projects about the subject in a bid to prevent any further unnecessary duplication. The findings established that there were no ongoing or published articles on this topic. Consequently, we tried to register this systematic review and meta-analysis, but the system was restricted and did not register in the PROSPERO database. All relevant terms were searched interchangeably with either the Boolean operator “AND” or “OR” as indicated, and two independent reviewers (YDM and AA) who reached a consensus on every occasion without disagreements were involved. The search terms used in PubMed were ((((((((Prevalence[Text Word]) OR (Prevalence[Text Word])) OR (Magnitude[Text Word])) OR (Burden[Text Word])) OR (Epidemiology[MeSH Terms])) OR (Prevalence[MeSH Terms])) AND ((((((Infertility[Text Word]) OR (Sterility[Text Word])) OR (Sterile[Text Word])) OR (Infertility[MeSH Terms])) OR (Infertility, Female[MeSH Terms])) OR (infertility, male[MeSH Terms]))) AND ((((((((((“Coping Mechanism“[Text Word]) OR (“Stress Management“[Text Word])) OR (“Coping Strategies“[Text Word])) OR (Balance[Text Word])) OR (Resilience[Text Word])) OR (Adaptation[Text Word])) OR (“Emotional regulation“[Text Word])) OR (“Coping skills“[MeSH Terms])) OR (“Adaptation, Psychological“[MeSH Terms])))) AND (((((Female*[Text Word]) OR (Wom? n[Text Word])) OR (Male*[Text Word])) OR (M? n[Text Word])) OR (Couple*[Text Word])). This SRMA incorporates (1) all observational studies conducted on the prevalence and/or coping mechanisms of infertility among men, women or couples in Ethiopia; (2) all noninterventional studies (cross-sectional, mixed methods, qualitative and observational analytical descriptive studies); and (3) both published and unpublished (preprints, theses/dissertations) conducted in Ethiopia. The studies that were excluded from this SRMA were those that did not report on either the prevalence or coping mechanisms of infertility in Ethiopia, interventional studies (randomized and nonrandomized controlled trials), books, case series/reports, articles with overlapping outcomes (duplication), those written in a language other than English, narrative reviews, editorials, conferences, correspondence and letters to the editor. The detailed process of identifying eligible studies and the reasons for exclusion are presented in (Fig.  1 ). Fig. 1 PRISMA 2020 flow chart for the included studies [ 24 ] PRISMA 2020 flow chart for the included studies [ 24 ] The first search retrieved 312 articles plus 20 articles by hand searching the references of the included studies. However, after title screening, abstract, and full-text review, the final number of articles shortlisted for this review was greatly reduced. In the original collection, 65 duplicates were eliminated after being exported to EndNote 20 software, and 124 articles were excluded after title and abstract review, resulting in 143 articles. A full-text review of these articles yielded an exclusion of 132 articles, and 11 studies that met the inclusion criteria for this SRMA remained. Data were independently extracted by two reviewers (YDM and AAM). All studies that matched the selection criteria were imported into the EndNote 20 database. After the removal of duplicates, the titles and abstracts were evaluated for eligibility before full-text assessment. Full-text reviews that met the inclusion criteria were checked for quality thereafter via the Newcastle‒Ottawa Quality Assessment Scale (NOS), which was adapted for cross-sectional studies, and the JBI critical appraisal checklist, which was used for qualitative research. Data extraction from the included studies was performed via a table and an Excel spreadsheet. The following information was extracted from each study: (1) identification details (surname of first author with year of publication), (2) study design, (3) population with age, (4) study place (urban/rural), (5) sample size, (6) prevalence of outcome of interest (infertility), (7) data collection method, (8) types of coping mechanisms/strategies and (9) quality score. Two authors assessed the quality of the methodology, study population, sample size, comparability, and statistical analysis of each quantitative study conducted on infertility. In cases of disagreement (10%), a third author was involved, and the discussion led to complete resolution. The quality of the selected quantitative articles was assessed via the Newcastle‒Ottawa Scale (NOS), which was adapted for cross-sectional studies [ 25 ]. The score ranges from 0 to 10 points. Articles with a score of 7 and above were considered high quality, those with scores between 5 and 6 were deemed average quality, and those with a score of 4 and below were rated poor quality. No studies were removed because of poor quality in this review. Overlapping studies were excluded because they retained the most comprehensive, recent studies and were methodologically fit with this systematic review and meta-analysis. After the quality analysis of the included studies was completed, a data display matrix was created and is summarized in (Table  1 ). Similarly, the quality of qualitative studies was independently assessed by two authors (YD and AA) by using the Joanna Briggs Institute (JBI) critical appraisal checklist for qualitative research, which contains 10 critical questions [ 26 ]. Disagreements were resolved by the third author (HA). The JBI checklist promises rapid evaluation because it comprises ten items under a comprehensible checklist and applies to different qualitative studies. The quality of each study was, thus, categorized using this tool as YES to mean that this item was appropriate for the study; NO to mean this item was not appropriate for the study, and UNCLEAR indicated that it was not clear whether this item could be applied to the study and NOT APPLICABLE when the item was not applicable to the method. A score was given for each item that fell into the YES category, and all included qualitative studies were judged as having strong-quality results. In this systematic review and meta-analysis, we evaluated the prevalence of infertility and the associated coping mechanisms in Ethiopia. Clinical infertility is defined as the inability to conceive after 12 months or more of unprotected regular intercourse [ 27 ]. In the demographic approach, infertility is measured for women who were married or in a union for at least 5 years, never used contraceptives, and had an intention to conceive. The current duration approach includes the risk of pregnancy at survey time and determines the current length of time at risk of pregnancy at 12, 24, and 36 months. The review included both primary and secondary infertility among women, men and/or couples. Coping is a term referring to a set of one’s cognitive and behavioural efforts to interpret, analyze, and transform a stressful condition so that it may lessen discomfort [ 28 ]. Coping mechanisms refer to any behavior, mental, social interaction, or medical approach that individuals or couples use to deal with the emotional, social, or physical effects of infertility. In this review follow the most widely used classification, Lazarus and Folkman’s (1984) coping theory, which divides coping strategies into problem-focused and emotion-focused coping strategies. Other models also incorporate avoidance, meaning-based, and social coping [ 21 ]. Hence, in this SRMA, the coping mechanisms identified in the included studies are religious activities, traditional activities, medical treatment, informal fosterage/adoption of children in informal ways, marital separation and acceptance, engaging in extramarital relations, faith and resilience (if God wills, it will happen), having a God child, and allowing a husband to bore from others. The data were synthesized independently for the prevalence and coping mechanisms of infertility. Statistical pooling (meta-analysis) was performed to quantify the magnitude of infertility in Ethiopia. The check for any possible publication bias was performed via a funnel plot and Egger’s regression test. The significance level for the heterogeneity test and Egger’s test was considered statistically significant for a p value < 0.05. The decision regarding what meta-analysis model to use depends upon the evaluation of heterogeneity between the studies. According to Higgins et al., I2 values  75% represent low, moderate, and high levels of heterogeneity, respectively [ 29 ]; therefore, we would have attempted to pool these values via fixed-effects models if heterogeneity was < 50%. However, there was high heterogeneity among the studies. Thus, the pooled prevalence estimates were computed under the random-effects model, which accommodates both within- and between-study variations. Stata version 17.0 was used for the meta-analysis. Additionally, subgroup analyses were performed according to the study location and type of infertility. We have been planned to identify, extract data and analyze mechanisms of exposure and their proposed biological or psychosocial pathways leading to infertility. These mechanisms would be synthesized narratively, and where sufficient data would be available, subgroup meta-analyses and meta-regression would be performed to assess the relationship between specific exposures and infertility prevalence, thereby exploring possible causal pathways. But this SRMA aimed to determine the pooled prevalence of infertility and identify the coping mechanisms. In addition, there was no adequate study in Ethiopia that showed factor analysis for infertility. Hence, the relationship between specific exposures and infertility was not examined in this SRMA. For each study included, we extracted direct descriptions of the coping strategies reported and grouped them into themes. These themes generally included problem-focused, emotion-focused, and avoidance-based coping; informal social support; spiritual or religious practices; and medical interventions. We summarized the qualitative findings by identifying common patterns among the studies through thematic analysis. When coping mechanisms were reported with numbers, such as how often or what percentage of participants used specific strategies, we described these findings as well. We did not perform a meta-analysis for coping mechanisms because of the differences in measurement tools and reporting formats.

Infertility can be defined in different ways. The clinical definition of infertility is the failure to achieve conception after 12 months or more of regular unprotected sexual intercourse [ 1 ]. From a demographic point of view, infertility is defined as a lack of live birth in a woman of reproductive age of 15–49 years with regular unprotected sexual intercourse [ 2 ]. Infertility is classified as primary or secondary. Primary infertility applies to women who have never been pregnant/conceived. Secondary infertility occurs when at least one conception has occurred but has never been repeated [ 3 ]. Various studies have shown that infertility affects approximately 10–15% of couples worldwide [ 4 , 5 ]. According to a National Survey of Family Growth report from 2006 to 2010, 6% of married females in the age group 15–44 years in the United States of America (USA) are infertile [ 6 ]. In contrast, infertility in China accounts for approximately one-fourth of childbearing-aged couples [ 7 ]. A systematic review suggested that the lifetime prevalence of infertility is 17.5%, and the period prevalence is 12.6% [ 8 ]. In sub-Saharan Africa (SSA), infertility rates generally range from 30% in Nigeria to 9% in Gambia [ 9 ]. A comprehensive analysis based on the findings of the Ethiopian Demographic and Health Survey (EDHS) of 2016 estimates the prevalence of infertility in Ethiopia; according to a demographic definition, it was 7.6%, and primary and secondary infertility rates were found to be 1.4% and 8.7%, respectively. According to the current duration approach definition, the overall prevalence of infertility is 24.1.1% at 12 months, 13.4% at 24 months and 8.8% at 36 months [ 10 ]. The causes of infertility might be due to the man, the woman, or both. However, prevailing social and traditional beliefs wrongly attribute infertility to women alone [ 11 ]. In developing countries, most of these causes are possibly due to infection. Infections account for most of the etiologies of infertility in African women whereas approximately 46% of infertility in men in SSA is attributed to sexually transmitted diseases (STDs) [ 12 , 13 ]. The female-related factors include obesity, obstruction of fallopian tubes, endometriosis, ovarian surgery, chemotherapy and radiotherapy, and uterine problems [ 14 ]. The well-known male factors are disorders of low testosterone concentrations or low sperm counts and semen volume, azoospermia, lifestyle problems such as tobacco use and obesity, psychological problems, and chromosomal abnormalities [ 15 , 16 ]. The overall prevalence of infertility-related stress in Ethiopia was 92.71%. The stress was greater among women with the following characteristics: being older than 35 years, living in a cohabitating marriage, being childless, and having infertility for 4–6 years. However, there is not enough evidence that infertility-related stress varies with education, income, knowledge of the cause of infertility, or history of past treatment [ 17 ]. Infertility is much more than a quality-of-life concern. Its consequences stream into public health domains such as psychological distress, social stigma, economic stress, marital disagreements, poor pregnancy outcomes, and later adult diseases. It poses a threat to the health of infertile individuals, and this impact resides within the framework of the cognitive and defense mechanisms of individuals [ 18 ]. According to research, approximately 25% of women affected by primary infertility use distraction techniques such as work as a coping strategy, whereas only 10% of women with secondary infertility do so. Some women actually avoid discussion of the inability to conceive and of all the reasons why they cannot have children with their husbands [ 19 ]. There was a strong positive correlation between perceived stress and coping strategies in both sexes. Stress further predicts the types of coping strategies employed by these individuals [ 20 ]. Women suffering from secondary infertility have a greater prevalence of religious denial coping strategies than women suffering from primary infertility [ 21 ]. In Ethiopia, women with infertility employ various coping strategies to address their problems. The most common strategies are spiritual (religious) strategies, predominantly traditional methods, medically inclined approaches, and informal fosterage [ 22 ]. This systematic review and meta-analysis, therefore, attempts to answer the question of the pooled prevalence of infertility and associated coping mechanisms for infertility in Ethiopia.

This SRMA evidence from studies in Ethiopia aimed at determining the pooled prevalence of infertility and the associated coping mechanisms. By employing a comprehensive search and following PRISMA-guided methodology, we pooled estimates of prevalence and narratively synthesized coping mechanisms. The results confirm that infertility in Ethiopia is relatively high, with varying coping responses and indeed a major public health issue. Infertility has become a public health agenda at the global level, affecting the personal, social, and economic life of an individual and that of the family as a whole. The variation in the definition, diagnostic cutoff points, study design, research methods, and source population makes the performance of meta-analyses on infertility difficult. Population-based studies, demographic and health survey reports, and institution-based studies have reported the prevalence, classification, and ability to cope with infertility. Each method thus has advantages and disadvantages. Cox et al. identified that estimates of infertility are much needed for guiding the planning and coordination of the prevention, diagnosis, and treatment of infertility, chiefly estimates that are in agreement with clinical definitions that may serve as guides for services [ 8 ]. In this SRMA, the overall pooled prevalence of infertility is higher than that of the global SRMA conducted by Cox, C.M., et al.; showed that the pooled estimates of lifetime and period prevalence of 17.5% and 12.6% respectively [ 8 ]. The pooled prevalence of infertility reported in the present review aligns with estimates for several low- and middle-income countries (LMICs), yet appears slightly higher than the global average of approximately 8–12% reported in multi-country analyses [ 40 ]. The latest WHO estimates indicated that approximately 17% of adults globally, roughly 1 in 6, experience infertility during their lifetimes, with minimal variation across income levels [ 40 ]. The reason for the discrepancy may be attributed to methodological differences, socioeconomic differences, the number of studies included, and the diagnostic criteria used, as only five cross-sectional studies were reported in this SRMA than that of 133 studies globally. Studies from sub-Saharan Africa, including Nigeria, Cameroon, and Mali, have documented infertility ranging from 11 to 16%, largely driven by secondary infertility from preventable causes such as reproductive tract infections, unsafe abortions, and postpartum complications [ 41 ]. This is in line with the current SRMA, identified similar etiological patterns, including pelvic inflammatory disease, unsafe abortion, and postpartum complications, though nationally specific pooled estimates remain limited [ 10 ]. High-income countries such as the United States, Canada, and those in Western Europe report a lower burden of secondary infertility, with primary infertility more often linked to age-related decline, lifestyle factors, and delayed childbearing [ 5 , 6 ]. These differences reflect variations in infection control, access to reproductive health services, and utilization of assisted reproductive technologies especially in developed countries including Ethiopia. On the other hand, this review is lower than other global SRMA investigated by Hazlina, Norhayati, Bahari, & Arif, which reported a pooled prevalence of 46.25% for overall infertility and 51.5% for primary infertility [ 42 ]. This difference might also be due to sociocultural variation, sample size, number of studies included, region, and study characteristics, as the latter review included 32 studies and was conducted globally. The subgroup analysis of primary infertility, secondary infertility and overall infertility of the current SRMA are nearly similar for overall prevalence but lower for primary and secondary infertility than that reported in the SRMA conducted in Sudan by AA, Ahmed, & Oladokun [ 43 ]. The most likely reasons for this discrepancy in primary and secondary infertility might be the improvement in the diagnosis and treatment of sexually transmitted infections (STIs) in Ethiopia, the difference in inclusion criteria, as both English and Arabic were used in Sudan, and the small number of studies included in our review. Many studies have indicated that infertility type is associated with infections, predominantly STIs and postpartum infections. The studies conducted by Abebe et al., Elhussein et al., and Sun et al. identified that if STIs and postpartum infections are present in high numbers, then it is expected that secondary infertility will also increase [ 18 , 44 – 46 ]. In contrast, some meta-analyses in Africa investigated by Badawi and Elawad reported no significant difference in the prevalence of primary and secondary infertility [ 47 , 48 ]. The pooled prevalence of overall infertility in this review was lower than that reported in studies conducted in Africa by Abebe et al., [ 45 ]. The main reasons for this difference might be attributed to sociocultural disparities among countries, and 21 observational studies were included in Africa, whereas only five studies were included in our review. Infertile people use different coping mechanisms or strategies to overcome the impact associated with infertility. Cultural and social contexts significantly shape both the causes and coping mechanisms surrounding infertility in Ethiopia. In many Ethiopian communities, the high value placed on childbearing, and strong gendered expectations frequently result in women being blamed even when male or combined factors are involved. Such stigma can delay health-seeking behavior and drive couples toward traditional healers, herbal remedies, or religious interventions instead of biomedical care [ 38 ]. Consequently, coping strategies tend to be deeply rooted in religious and cultural traditions. These include using holy water (“tsebel”) , prayer, informal adoption/fostering, and seeking support within extended family networks; methods that diverge sharply from the structured support groups, psychological counselling, and assisted reproductive technologies; which is more commonly used in high-income countries [ 49 ]. These cultural and contextual differences not only shape the choice of coping mechanism but also influence mental health outcomes, resilience, and willingness to seek biomedical intervention. In this review, each participant visited a minimum of 3 or 4 health facilities. Many women were informed about the unavailability of the remedy in the country, yet some continue seeking help [ 36 ]. This highlights the necessity of developing better, more advanced treatment modalities. Many different negative emotional and psychological effects have been reported. Supportive or destructive changes were observed among relatives and friends. Treatments by in-laws and neighbours were mostly negative, as identified by Meskelu and Berhane [ 36 ]. This is supported by Schmidt and Holnstein; poor spousal communication coupled with the avoidance coping strategy yields significantly high infertility-specific distress among both genders. For an infertile couple, choosing the appropriate coping strategy becomes imperative to lessen distress. The coping mechanisms now come into consideration for the psychotherapeutic treatment of infertility [ 50 , 51 ]. Based on the included studies investigated by Adane, Berhanu, & Sewagegn and Araya et al. 2025, there were Christians who prayed a lot and quite frequently attended churches for that very reason. Orthodox Christians organize different ceremonies and prayers for people who seek to have a child and, on certain occasions, attend these events. Muslims also ask another person or a friend to pray for him/her [ 34 – 39 ]. This is supported by a study in Cameroon in which almost all participants reported praying and being active as their main coping mechanisms [ 52 ]. On the other hand, this is contrary to the evidence in Iran, which shows that there is an increase in emotional coping strategies. An increase in emotional coping strategies is considered to be due primarily to an absence of control over life events, a low self-esteem level, a lack of social support, and a high level of stress among infertile individuals [ 53 ]. In this review, a study conducted by Adane et al. infertile women suffer from psychological distress as a result of infertility and use a variety of coping strategies to address their ongoing problems [ 37 ]. This is in line with the study conducted in Mali, by Hess, Ross, & Gililland Jr, 2018, where sociocultural pressure has led to physical and social weakness in women, who find themselves translating into a combination of traditional and biomedical therapies along with religious practices. The increase in psychological distress in many comes as a result of a lack of success. Care providers need to assess the general and psychological health of infertile women and care for them in a culturally contextual way to improve their health status and quality of life [ 54 ]. Infertile women resort to other means to cope with their problems, such as marital separation and accepting their case. Women personally express infertility-related stress by crying, forgetting, disquiet, and lacking or deprived of sleep [ 37 ]. Similarly, Simionescu et al. reported that infertile couples experience significantly more stress and are more likely to develop psychological disorders than healthy, normal couples [ 55 ]. Based on the article investigated by Mekonnen, infertility includes various complex problems, such as dissatisfaction with marriage and sexual relationships, and social, economic, and psychological ramifications. More importantly, infertile people face social stigma and discrimination in society [ 35 ]. This finding contrasts with other studies conducted by Ismail & Moussa that have shown that infertile women resort to more passive avoidance coping strategies than other coping strategies [ 56 ]. Prolonged infertility has wide-reaching effects on women’s lives, including psychological, financial, sociocultural, and spiritual effects. As per Araya et al. despite the difficult paths of infertility, women acquire or develop different coping mechanisms and resilience [ 34 ]. Hence, much professional psychosocial support is needed to alleviate the effects of infertility on individuals, but there is inadequate access to and utilization of these services in Ethiopia. Infertility requires more attention in the Ethiopian healthcare system since it greatly influences the lives of couples. According to the research investigated by Belete, women perceived themselves to be sterile for reasons undeserved by God. They perceived infertility to be attributed to many other causes, such as the use of contraceptive birth control methods, hereditary reasons, God not wanting them to conceive, and STIs. They experienced verbal abuse, isolation, conflict, and negative treatment from the community and close relatives. Then, there were further hardships that entailed hitting, divorce, and maltreatment by their husbands. Some major coping strategies these women sought to solve their problems were living a spiritual life, being a parent to God’s child, and adopting children through informal means [ 39 ]. This finding is supported by the qualitative study conducted by Mashaah, Gomo, Maradzika, Madziyire, & January, which revealed that for infertile women, despair and sorrow from infertility are exacerbated by the blame they are made to face from families and communities that stigmatize them. This has given rise to names to qualify their condition. That has subjected them to social ridicule and contempt. Such treatment incites these women into developing mechanisms to address such ugly experiences [ 57 ]. This study employed thorough search strategies and thus considered published, unpublished, and gray literature data. The evaluation of the methodological quality of the studies was performed via a standardized tool. Another strength of this review is that it provides valuable national information regarding both the quantitative and qualitative aspects of infertility for national health policymakers and health professionals, but it might have limitations due to the cross-sectional nature of the studies. Although the review identified reports on female, male, and combined causes of infertility, the lack of standardized and comparable quantitative data on prevented separate meta-analyses by cause and association of factors, which may limit the specificity of the findings. Additionally, some of the articles had small sample sizes, which calls into account their representativeness. The inclusion of only articles in the English language in this review could not be a limitation since, in our country, publications without the English language are null. There is limited evidence of infertility in Ethiopia, which highlights the insufficiencies of the data used to determine the prevalence of infertility and the immediate need for more comprehensive research to measure infertility prevalence and its coping mechanisms in Ethiopia. Compared with the global standard, the pooled prevalence of infertility in our study was relatively high. Infertile women adapt different coping strategies, such as religious, traditional, medical, adoption, acceptance of the case, and even marital separation. The health delivery system and health service providers need to look at the psychosocial aspects of advanced infertility treatment options. In addition, exploration of life experiences through further studies is essential, preferably at the community level. In Ethiopia, infertility is associated with a lot of emotional trauma, stigma and pressures on marital life. To cater to psychological support for dealing with the effects of infertility such as depression, anxiety and social isolation within the shortest possible time by health professionals, mental health therapy and supportive groups should be included as part of infertility care. Healthcare providers should direct evidence-based treatment while respecting cultural beliefs about these services. Clinicians should educate the public to challenge misconceptions and facilitate joint responsibility in the management of infertility. Policymakers and clinicians should advocate low-cost services for infertility. Continuing education should include training in empathetic communication and coping strategy guidance for infertility care.