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Delayed, fragmented, inequitable: a global qualitative systematic synthesis of fertility care pathways and
Anna Afferri1, Joanna Apps2, Michelle Crowther3
1School of Nursing, Midwifery, Allied, and Public Health (SoNMAPH), Canterbury Christ Church University, Canterbury, UK.
Background:
Infertility is a prevalent reproductive health condition that affects one in six people worldwide. Despite recent increasing recognition of the global burden of infertility, a large fertility care gap remains, with limited understanding of the determinants of care-seeking among those who require infertility services to achieve their desired family size.
Objective And Rationale:
To date, there has been no comprehensive global thematic synthesis specifically focused on the qualitative evidence regarding determinants of fertility care-seeking. This review aims to identify and to systematize these determinants across diverse populations, settings, and health systems, drawing on a candidacy-informed framework to support more equitable, person-centred fertility care. The research question focuses on what determinants shape care-seeking among people with infertility and how these can be utilized to guide interventions, services, and future research.
Search Methods:
Seven databases were searched up to May 2026, complemented by citation tracking, to identify qualitative and mixed-methods studies documenting determinants of fertility care-seeking among affected individuals and couples. The quality of included studies was appraised using the Joanna Briggs Institute checklist; data were inductively coded and thematically synthesized, mapped to socio-ecological levels, and interpreted through a candidacy lens. Confidence of the evidence in each synthesized finding was assessed using GRADE-CERQual.
Outcomes:
Twenty-seven studies from low-, middle-, and high-income countries involving users of biomedical, traditional, complementary, and cross-border fertility care were included. Determinants of care-seeking clustered into six domains: individual (e.g. personal fulfilment, fertility knowledge, age, psychological factors, gender norms); relational (e.g. couple dynamics, decision-making, negotiation, gendered power relations, masculinity norms); socio-cultural (e.g. stigma, social expectations, familial, and peer influences); socio-economic (e.g. financial barriers, health insurance coverage); health system and therapeutic (e.g. service quality, treatment costs, medical pluralism, public-private sector dynamics, availability of Medically Assisted Reproduction/ART, geographical accessibility, waiting times); and policy and political (e.g. infertility inclusion in national policies, regulatory frameworks, cross-border fertility care). Care pathways were typically non-linear, gendered, and diverse, characterized by delayed recognition of infertility as a health concern, medical pluralism, care interruptions, and re-engagement over time, often at considerable emotional and financial cost.
Wider Implications:
Multiple individual, relational, social, and structural determinants affect care-seeking for infertility. Multi-level policy, financing, and service delivery interventions are needed to address stigma, gendered norms, financial hardship, regulatory barriers, and often fragmented, pluralistic care pathways. This synthesis offers a candidacy-informed, multi-domain framework to guide context-sensitive interventions, including integrating infertility into universal health coverage, strengthening regulation of cross-border care, and embedding culturally competent, patient-centred fertility care within sexual and reproductive health programmes, and health systems.
Registration Number:
CRD420251163735.