Analysis of status and influencing factors of knowledge, attitudes, and expectations towards assisted reproductive technology among infertile women in Lebanon: A cross-sectional study.

Infertility impacts millions of individuals of childbearing age worldwide. It is estimated that approximately 48 million couples and 186 million people globally are living with infertility [ 1 ]. Based on global-metrics data sets, in 2025, Lebanon’s fertility rate stands at 1.99 births per woman, marking a 0.6 decline from 2024, and projections indicate a downward trend until 2050 [ 2 ]. The World Health Organization (WHO) defines infertility as a disease of the male or female reproductive system, characterized by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse [ 1 ]. The causes of infertility are equally divided between both genders, with male and female factors each contributing to around 35% of cases. In 20% of cases, a combination of both factors is involved, while 10% remain unexplained [ 3 ]. The management of infertility has evolved over the past four decades to include ART, which was a revolutionary in the study of medicine. The WHO, in collaboration with various societies such as the American Society for Reproductive Medicine, the European Society for Human Reproduction and Embryology and others, has standardized numerous definitions used in medically assisted reproduction [ 4 ]. ART is defined as any treatment or procedure that involves the in vitro handling of human oocytes, sperm, or embryos to establish a pregnancy [ 4 ]. This encompasses techniques such as in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), preimplantation genetic testing (PGT), and others, but doesn’t include intrauterine insemination (IUI) [ 4 ]. There are several indications for the use of ART in both men and women, including tubal factor infertility, diminished ovarian reserve, ovulatory dysfunction, oligospermia or azoospermia, and unexplained infertility [ 5 ]. Fortunately, fertility treatment centers are growing rapidly in the Middle East, outpacing development in Europe and North America. For instance, Iran has over 70 IVF centers, and Turkey has more than 110, along with active centers in the United Arab Emirates, Egypt, Jordan, and Saudi Arabia [ 6 ]. Additionally, lower treatment costs make infertility services more accessible in the Middle East [ 7 ]. In Lebanon, there is no specific law or regulation specially dedicated to the reproduction practices. Provisions within the 1994 law of medical ethics permit artificial insemination or pregnancy by using assisted fertility techniques for married couples [ 8 ]. Despite the ongoing widespread use of assisted reproduction across the world, previous studies indicate that women have misconceptions about ART [ 9 , 10 ]. For instance, an Iranian study shows that about 63.8% of the group studied had poor knowledge, 26.9% had fair knowledge, and less than 10% had good knowledge [ 11 ]. Other research shows that public attitudes in the United States of America and many other Western countries toward ART are positive [ 12 , 13 ]. When it comes to the expectations, a Brazilian study found that 42% of women seeking fertility treatment expected their chances of pregnancy after a single IVF cycle to be over 60% [ 14 ]. Although Lebanon lacks comprehensive data on the utilization of assisted reproduction, there is a noticeable presence of well-established IVF centers, and many individuals and couples are pursuing IVF treatments. This is supported by a cross-sectional study published in 2020, which surveyed over 600 Lebanese individuals regarding their knowledge and perceptions of infertility. The study found that 93.9% of respondents believe infertility should be medically treated, 92.3% think it is socially acceptable to seek medical fertility treatment, 82.8% find it acceptable to use IVF if infertile, and 66.2% believe that using IVF is acceptable according to their religion [ 15 ]. Nevertheless, previous research in Lebanon shows that women’s fertility quality of life is lower compared to Western countries, influenced by factors such as difficulties in conceiving, not having children, and facing societal stigma [ 16 ]. Given the increasing prevalence of infertility and broader access to ART services in Lebanon, there is a noticeable gap in research regarding how Lebanese women perceive these treatments. This study, therefore, aims to assess the knowledge, attitudes, and expectations of Lebanese women experiencing difficulty conceiving with regard to ART, and explore the associated factors that influence each.

The study included 346 women, with a mean age of 34 years (± 6.48 years). Of these, 53.47% were from Azoury clinic, and 46.5% were from Hope clinic. Half of the participants are workers, 53.47% lived in central areas, and 57.51% had health insurance. Additionally, 90.46% were non-cigarette smokers, 63.29% were non-nargileh smokers, and 88.44% non-alcohol consumers. For the past medical history, 38.2% had at least one chronic disease. Among these, obesity (53.78%) and thyroid disorders (25%) were the most common. Among the participants, 34.39% had routine Pap smears, and 52.02% had at least one previous gynecological surgery. Among women with a history of gynecological surgery, cesarean section (38.89%) and laparoscopy (36.67%) were the most frequent. Difficulty conceiving was primarily due to female factors (41.91%), such as Polycystic Ovary Syndrome (PCOS) (36.56%), ovulatory disorders (33.10%), and endometriosis (28.97%). Among those who reported infertility due to male factors, low sperm count (93.75%) and low sperm quality (92.50%) were common issues. Also, 9.83% had a family history of infertility, predominantly on the mother’s side (52.94%) ( Table 1 ). Abbreviations: BMI = Body Mass Index, N = Frequency, SD = Standard Deviation, USD = United States Dollar. The results showed a mean knowledge score of 8.36 ± 1.91 (median = 9; range = 0–10). Of the participants, 195 (56.4%) demonstrated high knowledge, while 151 (43.6%) had moderate to low knowledge ( Table 2 ). The results showed a mean attitude score of 49.5 ± 5.43 (median = 50; range = 12–60). Of the participants, 190 (54.9%) demonstrated positive attitudes, while 156 (45.1%) demonstrated negative attitudes ( Table 3 ). The results showed a mean expectation score of 5.12 ± 1.55 (median = 5; range = 0–9). Of the participants, 255 (73.7%) demonstrated high expectations, while 91 (26.3%) demonstrated low expectations ( Table 4 ). Higher mean ART knowledge scores were significantly associated to living in rural areas (p = 0.009), exercising (p = 0.028), a history of ART use (p < 0.001), gynecological surgery (p = 0.015), laparoscopy (p = 0.035), and learning about ART from a doctor (p = 0.009) or the internet (p = 0.013). Longer marriage duration also correlated positively with knowledge (p = 0.007). Conversely, more frequent nargileh use was negatively associated with ART knowledge (p = 0.009) ( Table 5 ). * Mann-Whitney U test. Rs = Spearman correlation coefficient, Y = Yes. Variables that lacked significance with the knowledge score (Azoury/hope clinic p = 0.659, age p = 0.187, BMI p = 0.855, residence p = 0.71, monthly income p = 0.135, cigarette smoking p = 0.177, nargileh smoking p = 0.102, educational level p = 0.091, health insurance p = 0.919, occupation p = 0.712, chronic disease p = 0.925). Higher mean attitude scores were significantly associated with living in rural areas (p = 0.028), higher education level (p = 0.023), having health insurance (p = 0.025), and a history of gynecological surgery (p = 0.001), cesarean section (p = 0.012), and laparoscopy (p = 0.004). Additionally, regular menstrual periods (p = 0.01), previous pregnancies (p = 0.006), ART utilization history (p = 0.001), hearing about ART from the doctor (p = 0.017), and recognizing advanced female age as a cause of infertility (p = 0.038) were also linked to higher attitude scores. Age (p < 0.001), weight (p = 0.02), BMI (p = 0.048), and duration of marriage (p = 0.044) showed positive correlations with attitude scores ( Table 6 ). * Independent samples t-test and One-way ANOVA. ** Post-hoc analysis: Educational level (post-graduate vs elementary or intermediate p = 0.026, post-graduate vs university degree p = 0.237, post-graduate vs high school p = 1, post-graduate vs no education p = 1). R = Pearson correlation for normally distributed variables and Spearman correlation for non-normally distributed ones. Variables that lacked significance with the attitudes score (Azoury/hope clinic p = 0.327, exercising p = 0.745, cigarette smoking p = 0.697, nargileh smoking p = 0.944, alcohol consumption p = 0.307, residence p = 0.15, occupation p = 0.175). Higher mean expectations scores were significantly associated with higher family income (p = 0.003), different fertility clinics (p < 0.001), a history of gynecological surgery (p = 0.028), cesarean section (p = 0.003), regular menstruation (p = 0.044), and ART utilization history (p = 0.002). Participants with no history of hypertension (p = 0.044) and visual problems (p = 0.008) were linked to higher expectations scores. Besides, BMI (p = 0.021) showed a negative correlation with expectations towards ART ( Table 7 ). * Independent samples t-test and One-way ANOVA. ** Post-hoc analysis: family income ( 2000 USD p = 0.005, 250–500 vs > 2000 USD p = 0.048, > 500–1000 vs > 2000 USD p = 1, > 1000–2000 vs > 2000 USD p = 1). Rp = Pearson correlation. Variables that lacked significance with the expectations score (age p = 0.709, duration of marriage p = 0.082, residence p = 0.146, educational level p = 0.245, cigarette smoking p = 0.558, nargileh smoking p = 0.123, exercising p = 0.206, health insurance p = 0.495, living area p = 0.238, occupation p = 0.51). The results from the first GLM, with the knowledge score as the dependent variable, showed that having a history of previous ART utilization increases the knowledge score by 0.151 points. Similarly, receiving information about ART from a doctor (β = 0.064), female age (β = 0.005), and physical exercise (β = 0.119) were positively associated with higher knowledge scores. On the other hand, factors such as higher family income (β = −0.133), a medical history of immunodeficiency (β = −0.275), living in centers (β = −0.066), and more frequent exercise per week (β = −0.028) were significantly associated with lower knowledge scores. The second GLM analysis, with attitudes score as the dependent variable, showed that residing in South Lebanon (β = 6.136), North Lebanon (β = 4.624), Bekaa (β = 5.359), Beirut (β = 5.321), and Mount Lebanon (β = 4.979) were significantly associated with higher attitudes scores compared to residing in Nabatiyeh. Additionally, having a history of ovarian cyst removal (β = 2.065), receiving information about ART from a doctor (β = 1.151), and female age (β = 0.120) were also linked to more positive attitudes towards ART. In contrast, living in centers (β = −1.835), having a regular menstrual period (β = −1.521), and having a medical history of asthma/COPD (β = −3.781), gastric ulcers (β = −3.947), or epilepsy (β = −5.192) were significantly associated with lower attitudes towards ART. The third GLM analysis, with expectations score as the dependent variable, revealed that reporting hormonal disorders as a cause of female infertility (β = 2.758) was significantly associated with higher expectations regarding ART. In contrast, advanced female age (β = −0.768) and being a patient at the Hope clinic (β = −0.7) were significantly associated with lower expectations ( Table 8 ). *Reference residence = Nabatiyeh. Positive attitudes and higher expectations are significantly correlated with higher knowledge scores on ART (p < 0.001). Also, higher knowledge and expectations are significantly correlated with more positive attitudes towards ART (p < 0.001). Also, higher knowledge and attitudes are significantly correlated with greater expectations towards ART (p < 0.001) ( Fig 1 .). * GLM with a linear scale for normally distributed scores and a gamma log link for non-normally distributed ones.

This manuscript is not under consideration for publication elsewhere. All authors have approved the manuscript for submission, and the research has received approval from the institutional review board of the School of Pharmacy at the Lebanese University and the Clinical Research Unit at Al Zahraa Hospital University Medical Center. If accepted, this article will not be published elsewhere in the same form, in English or any other language, without written consent from the copyright-holder.

This study highlights important sociodemographic, clinical, and behavioral factors associated with knowledge, attitudes, and expectations toward ART among women facing infertility in Lebanon. While many women demonstrate good understanding, positive attitudes, and expectations toward ART, these are shaped by several factors such as age, education, medical history, lifestyle, and socioeconomic conditions. Recognizing these influences can help clinicians and policymakers address gaps in reproductive health services through targeted interventions, including integrating ART education into primary care, overcoming financial and accessibility barriers, providing psychological support, and tailoring a personalized, holistic approach. Due to the study design and the sensitive nature of the topic, the findings cannot be generalized to the broader population. Therefore, future research should further explore how socioeconomic, geographic, and psychosocial factors affect ART outcomes and assess the knowledge in the general population to facilitate early support. This also underscores the need for collaborative legal frameworks to address ethical and social challenges related to ART.

This cross-sectional study was conducted from June 1, 2024, to September 30, 2024, at Hope Clinic (Al Zahraa Hospital University Medical Center), a private university-affiliated teaching hospital, and Azoury IVF Clinic (Mount Lebanon Hospital), a private referral center—both located in Beirut. A simple random sampling method was employed; patients were selected from those seen by participating clinicians. Eligible individuals were approached and invited to participate, and those who consented were individually interviewed by three researchers—one PhD candidate and two Master’s students in Clinical Research and Pharmacoepidemiology using a structured paper questionnaire. Participation was anonymous and voluntary, with written consent obtained. To ensure anonymity, consent forms were stored separately from the completed questionnaires, which contained no personal identifiers. The three interviewers coordinated through regular team meetings throughout the data collection period to discuss any discrepancies and ensure consistency in interviewing techniques. Interviews were conducted in Arabic and took 12–15 minutes to complete. The study included Lebanese married women of reproductive age (≥18 years), actively attempting to conceive, and diagnosed with infertility regardless of the infertility source. Infertility was defined as the inability to conceive after one year of unprotected intercourse. Exclusion criteria were women with incomplete questionnaires (any questionnaire with missing responses in any section). The sample size was calculated using the standard formula for estimating a proportion in a finite population survey through Epi Info software [ 17 ]. The formula used: n = N × Z 2 × p × ( 1 − p ) d 2 × ( N − 1 ) + Z 2 × p × ( 1 − p ) N is the total Lebanese population size in 2024 (N = 5,800,000), z is the z-score corresponding to the desired confidence level (1.96 for 95% confidence level), d = 0.05 margin of error, and an expected infertility prevalence of 0.343, resulted in a target sample size of 346 participants [ 18 , 19 ]. The questionnaire was developed following a comprehensive review of the literature and was structured into three main sections. The first section included 23 questions addressing socio-demographic (residence, medical insurance, income, educational level, etc.) and lifestyle factors (smoking, alcohol consumption, physical exercise, etc.) [ 20 ]. The second section included 16 questions on health status, covering chronic conditions (hypertension, diabetes, dyslipidemia, etc.), gynecological history (menstruation, history of pregnancy, history of gynecological surgery, etc.), and infertility history (e.g., causes, family history) [ 21 – 24 ]. The third section contained 10 questions assessing knowledge of ART (with responses of “Yes,” “No,” or “I Don’t Know”), 12 questions evaluating attitudes towards ART (using a Likert scale), and 9 questions examining expectations related to ART (with responses of “Yes,” “No,” or “I Don’t Know”) [ 11 , 25 – 28 ]. The questionnaire was translated from English to Arabic and back-translated to ensure linguistic accuracy. To establish face and content validity, the tool was reviewed by two experts in the field of infertility, including an Obstetrics and Gynecology reproductive specialist and a maternal health researcher. It was pilot tested among 10–15 participants, which led to minor revisions. The data from the questionnaire were analyzed using SPSS version 26, with descriptive statistics, bivariate, and multivariate analysis. Frequencies were calculated for categorical variables, and means and standard deviations were used for continuous variables. The normality of continuous variables was assessed both graphically and statistically through skewness and kurtosis [ 29 ]. Bivariate analysis of qualitative variables was conducted using the independent samples t-test or one-way ANOVA with normally distributed scores, and the Kruskal-Wallis or Mann-Whitney U test with non-normally distributed scores. For continuous variables, Pearson correlation was used for normal data, and Spearman correlation for non-normal data. A Generalized Linear Model (GLM) was employed because the dependent variable, which is the knowledge score, was continuous but not normally distributed, which violates the assumptions of ordinary linear regression. The GLM also provided flexibility in handling multiple categorical independent variables. For the knowledge score outcome, a gamma distribution with a log link function was selected to account for the skewed distribution of the data, while attitudes and expectations scores were analyzed using a linear scale due to their normal distribution. Model adequacy and fit were further evaluated through the examination of residual plots. It allows for the identification of significant associated factors for each of the knowledge, attitudes and expectations scores, including variables with p-values <0.2. P-values <0.05 were considered statistically significant. Cronbach’s alpha was used to assess the internal consistency of the scores. While Cronbach’s alpha values of 0.7 and above are recommended [ 30 ], a value of 0.6 or higher can still be acceptable, especially in exploratory studies and social sciences research [ 31 ]. In this study, items with a Cronbach’s alpha of 0.6 or above were considered to have acceptable reliability. The alpha values for the knowledge, attitudes, and expectations scores were 0.63, 0.68, and 0.78, respectively. Individual scores for knowledge, attitudes, and expectations related to ART were calculated and used as dependent variables in analyses. As no standardized cut-off values exist for these scores, the cut-off points for each were determined post hoc based on the sample median. The 10-question knowledge score was scored 1 for correct answers and 0 for incorrect or “I don’t know” responses, with a range of 0–10. Scores 0–8 indicated low to moderate knowledge, and 9–10 indicated high knowledge. The attitudes score was based on a 12-question Likert scale from 1 (“Strongly Disagree”) to 5 (“Strongly Agree) ranging from 12 to 60. Scores <49 indicated negative attitudes, and those ≥50 indicated positive attitudes. The 9-question expectations score was coded 1 for “yes” and 0 for “no” or “don’t know,” with a range of 0–9. Scores <5 indicated negative expectations, and those ≥5 indicated positive expectations. This study employed a questionnaire for data collection, without invasive procedures or interventions. The study protocol, survey, and consent forms were reviewed and approved by the Institutional Review Board of the School of Pharmacy at the Lebanese University (7/24/D) adhered to the Declaration of Helsinki. Since the participating centers are private clinics without independent IRBs, the University’s IRB approval was accepted by these clinics to cover all study sites. Data was anonymous, non-identifiable, and stored according to the University’s data protection guidelines. Written informed consent was obtained, and participants were informed that their involvement was voluntary and they could withdraw at any time without justification.

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