Barriers and future strategies on establishing fertility preservation centers in a developing country: A scoping review

Abstract

Objective: To identify barriers and future strategies for establishing fertility preservation in developing countries.

Methods: A systematic literature search was conducted to identify studies/articles reporting in English on the barriers and strategies of fertility preservation in the developing countries. The literature search was conducted in PubMed, Cochrane Library, Scopus, and Google Scholar using search terms "challenges", "strategies", "fertility preservation", and "developing countries" to identify relevant sources from 2019 to 2024 applicable to current updates on fertility preservation.

Results: A total of 34 studies were included in the analysis. Barriers were identified on healthcare providers and patients. Moreover, it could also be categorized as the backbone of an established fertility preservation center, which is an accessible assisted reproductive technology (ART) center. Without an established ART center, maintaining and utilizing the fertility preservation center would be challenging. Lack of awareness was another main barrier identified among healthcare providers. From the patient's perspective, the main barriers identified were the lack of financial support for fertility preservation programs and the awareness of fertility preservation programs. Policy, sociocultural, religious, knowledge, access to service, competency, and attitude were the other barriers identified. Few studies addressed strategies. Several strategies were identified, including improving access to ART facilities, enhancing financial support and policy for targeted patients undergoing fertility preservation, and increasing knowledge and awareness of healthcare providers and patients. However, further investigation is warranted.

Conclusions: Several barriers have been identified for fertility preservation in developing countries. Therefore, corresponding strategies were proposed to specifically address them.

Keywords

Barriers / Future strategies / Fertility preservation / Developing countries / Reproductive health / Fertility services / Oncofertility

Conflict of interest statement

The authors declare no conflicts of interest.

Acknowledgements

We acknowledge Klinik Bahasa of Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Regina Arumsari and Hindun Wildani Wahab for their valuable proofreading inputs; Eri Dwi Suyanti and Khoiruddin Anshori for their technical assistance.

Funding

This study received no extramural funding.

Authors’ contributions

Agung Dewanto contributed to the development of the study’s conceptual framework, definitions, and overall design. Sarrah Ayuandari and Hana Nurhidayati Utami conducted the investigation, performed the literature search, and carried out data analysis. The manuscript was written, revised, and reviewed by Sarrah Ayuandari and Agung Dewanto.

Publisher’ s Note

The Publisher of the Journal remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

[1] Anazodo A, Laws P, Logan S, Saunders C, Travglia J, Gerstl B, et al. How can we improve oncofertility care for patients? A systematic scoping review of current international practice and models of care. Hum Reprod Update 2019; 25(2): 159-179.

[2] Asemota O, Klatsky P. Access to infertility care in the developing world: The family promotion gap. Semin Reprod Med 2015; 33(1): 17-22.

[3] von Wolff M, Andersen CY, Woodruff TK, Nawroth F. Ferti PROTEKT, Oncofertility Consortium and the Danish Fertility-Preservation Networks - What can we learn from their experiences? Clin Med Insights Reprod Health 2019; 13: 1-7.

[4] Kristensen SG, Wakimoto Y, Colmorn LB, Dueholm M, Pors SE, Macklon KT, et al. Use of cryopreserved ovarian tissue in the Danish fertility preservation cohort. Fertil Steril 2021; 116(4): 1098-1106.

[5] Woodruff TK, Ataman-Millhouse L, Acharya KS, Almeida-Santos T, Anazodo A, Anderson RA, et al. A view from the past into our collective future: The oncofertility consortium vision statement. J Assist Reprod Genet 2021; 38(1): 3-15.

[6] Kawai T, Harada M, Urata Y, Sanada Y, Kaneda Y, Takai Y, et al. Trends in fertility preservation treatments in Japan until 2023: Analysis of the Japan Oncofertility Registry. Int J Clin Oncol 2025; 30(4): 684-695.

[7] Go I, AA, Ouj U. Funding options for assisted reproductive technologies in developing countries. J Pregnancy Child Health 2016; 3(3): 1-3.

[8] Salama M, Ataman-Millhouse L, Sobral F, Terrado G, Scarella A, Bourlon MT, et al. Barriers and opportunities of oncofertility practice in nine developing countries and the emerging oncofertility professional engagement network. JCO Glob Oncol 2020; 6: 369-374.

[9] Dewi AK, Wicaksana AL, Lutfi M, Dewanto A. The barriers of joining in vitro fertilization programs among infertile couples in developing countries: A scoping review. Asian Pac J Reprod 2023; 12(4): 147-154.

[10] Ombelet W. Global access to infertility care in developing countries: A case of human rights, equity and social justice. Facts Views Vis Obgyn 2011; 3(4): 257-266.

[11] Ghazeeri G, Beyrouthy C, El-Taha L, Abiad M, Fahs D. Knowledge & attitudes toward fertility preservation (Medical and social freezing) among Lebanese women between the ages of 18 and 39 years. PLoS One 2023; 18(9): 1-12.

[12] Harzif AK, Santawi VPA, Maidarti M, Wiweko B. Investigation of each society for fertility preservation in Asia. Front Endocrinol (Lausanne) 2019; 10: 1-7.

[13] Peters MDJ, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc 2015; 13(3): 141-146.

[14] Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Ann Intern Med 2018; 169(7): 467-473.

[15] Salama M, Ataman L, Taha T, Azmy O, Braham M, Douik F, et al. Building oncofertility core competency in developing countries: Experience from Egypt, Tunisia, Brazil, Peru, and Panama. J Glob Oncol 2020; 4: 360-368.

[16] Takae S, Lee JR, Mahajan N, Wiweko B, Sukcharoen N, Novero V, et al. Fertility preservation for child and adolescent cancer patients in Asian countries. Front Endocrinol (Lausanne) 2019; 10: 1-10.

[17] Affdal AO, Grynberg M, Hessissen L, Ravitsky V. Impact of legislation and public funding on oncofertility: A survey of Canadian, French and Moroccan pediatric hematologists/oncologists. BMC Med Ethics 2020; 21(1): 1-11.

[18] Kassem L, Mellas N, Tolba M, Lambertini M, Oualla K. Awareness and practices of Arab oncologists towards oncofertility in young women with cancer. Ecancermedicalscience 2022; 16: 1388. doi: 10.3332/ecancer.2022.1388.

[19] Villarreal-Garza C, Martinez-Cannon BA, Barragan-Carrillo R, Bargallo-Rocha JE, Platas A, Pena-Curiel O, et al. Physicians’ attitudes, knowledge, and perceived barriers toward fertility preservation in young breast cancer patients in a developing country. Rev Invest Clin 2021; 73(6): 347-353.

[20] Zhang H, Wang G, Jiang B, Cao M, Jiang Q, Yin L, et al. Knowledge, attitude, and self-reported behaviors of oncology physicians regarding fertility preservation in adult cancer patients. J Cancer Educ 2020; 35(6): 1119-1127.

[21] Rashedi AS, De Roo SF, Ataman LM, Edmonds ME, Silva AA, Scarella A, et al. Survey of fertility preservation options available to patients with cancer around the globe. J Glob Oncol 2020; 6: 331-344.

[22] de Guzman GS, Manalo EM, Banal-Silao MJB. Awareness and perceptions of Filipino obstetrician-gynecologists on fertility preservation: A cross-sectional survey. BMC Womens Health 2023; 23(1): 1-7.

[23] Ozimek N, Salama M, Woodruff TK. National oncofertility registries around the globe: A pilot survey. Front Endocrinol (Lausanne) 2023; 14: 1-6.

[24] Ghazeeri G, Zebian D, Nassar AH, Harajly S, Abdallah A, Hakimian S, et al. Knowledge, attitudes and awareness regarding fertility preservation among oncologists in Lebanon. Hum Fertil 2016; 19(2): 127-133.

[25] Ayuandari S, Khasanah N, Riyanti I, Dewanto A, Sangun DIE, Wiweko B. Current awareness and attitude toward fertility preservation in Indonesia: A nationwide survey among health-care providers. J Hum Reprod Sci 2021; 14(1): 81-86.

[26] Harzif AK, Maidarti M, Silvia M, Mariana A, Mutia HD, Wiweko B. Knowledge, attitude, intention, and religion aspect toward fertility preservation among obstetrics and gynecology residents in Indonesia: A cross-sectional study. Int J Reprod Biomed 2020; 18(1): 47-56.

[27] Vesali S, Navid B, Mohammadi M, Karimi E, Omani-Samani R. Little information about fertility preservation is provided for cancer patients: A survey of oncologists’ knowledge, attitude and current practice. Eur J Cancer Care (Engl) 2019; 28(1): 1-8.

[28] Omani-Samani R, Vesali S. Preservation of childbearing potential in cancer survivors: A survey of gynecologists’ and embryologists’ current knowledge, attitude, and practice. J Cancer Educ 2020; 35(2): 327-333.

[29] Mailankody S, Bajpai J, Arora PR, Sreedharan R, Chitalkar P, Kurkure P. Oncofertility and pregnancy in adolescent and young adult cancers: Physicians’ knowledge and preferences in India. JCO Glob Oncol 2024; 10: 1-11.

[30] Mahajan N, Patil M, Kaur S, Kaur S, Naidu P. The role of Indian gynecologists in oncofertility care and counselling. J Hum Reprod Sci 2016; 9(3): 179-186.

[31] de Guzman GS, Manalo EM. Assessment of the knowledge, attitudes, and perceptions of Filipino obstetrics and gynecology residents on fertility preservation: A cross-sectional study. Ann Med Surg 2022; 84: 1-5.

[32] Malhotra N, Gupta M, Yadav A, Vanamail P, Mahey R. Knowledge, attitude, and intentions towards fertility preservation in cancer patients among healthcare workers in Northern India. JBRA Assist Reprod 2022; 26(3): 305-309.

[33] Wang Y, Chen H, Ju K, Kopp MF, Johnson SB, Farrell KK, et al. Female oncofertility attitude and knowledge: A survey of reproductive health professionals in Shanghai, China. Future Oncol 2019; 15(4): 371-379.

[34] Ju K, Kopp M, Wang Y, Yuan G, Zheng W, Ataman LM, et al. A survey study of attitude and knowledge regarding female fertility preservation among reproductive health professionals in Fujian, China. J Adolesc Young Adult Oncol 2019; 8(1): 67-73.

[35] Verduzco-Aguirre HC, Gulias-Herrero A, Bourlon MT. Oncofertility knowledge among internal medicine residents in an academic center in Mexico. J Cancer Educ 2022; 37(1): 10-15.

[36] Biskup E, Xin Z, Li R, Zucal JP, Lu Y, Sun Y, et al. Oncofertility knowledge and communication: Comparison between medical and surgical oncologists and breast cancer patients in academic Chinese centers. Front Surg 2021; 8: 1-12.

[37] Tholeti P, Uppangala S, Bhat V, Udupa KS, Kumar V, Patted S, et al. Oncofertility: Knowledge, attitudes, and barriers among Indian oncologists and gynecologists. J Adolesc Young Adult Oncol 2021; 10(1): 71-77.

[38] Küçük M, Yavaşoğlu I, Bolaman AZ, Kadıköylü G. Knowledge, attitudes, and practices of hematologists regarding fertility preservation in Turkey. Turk J Hematol 2013; 30(3): 269-274.

[39] Khalife D, Kutteh W, Tarhini H, Khalil A, Beyrouthy C, Ghazeeri G. Parental attitudes toward fertility preservation in female adolescent cancer patients in Lebanon. J Pediatr Adolesc Gynecol 2019; 32(5): 525529.

[40] Villarreal-Garza C, Mesa-Chavez F, de la Mora AP, Miaja-Avila M, Garcia-Garcia M, Fonseca A, et al. Prospective study of fertility preservation in young women with breast cancer in Mexico. J Natl Compr Canc Netw 2021; 19(13): 1-8.

[41] Chehin MB, Bonetti TCS, Serafini PC, Motta EL. Knowledge regarding fertility preservation in cancer patients: A population-based survey among Brazilian people during the pink October awareness event. JBRA Assist Reprod 2017; 21(2): 84-88.

[42] Osmani AH, Haider G, Ali S, Ali F, Irfan M, e Fatima D. Knowledge and perceptions about cancer treatment-associated infertility among young patients at a tertiary care hospital in Pakistan. Asian Pac J Cancer Prev 2017; 18(12): 3261-3265.

[43] Emirdar V, Karata li V, Acet F, Okay G, Gode F, Karabulut A, et al. Perspectives and knowledge about fertility preservation strategies among female cancer patients in Turkey. Int J Clin Pract 2023; 2023: 1-6.

[44] Wang M, Zhu L, Xiong H, Wang J, Li Z, Yang L, et al. Lack of knowledge, the main stumbling block of fertility preservation promotion in China. J Cancer Educ 2022; 37(3): 739-747.

[45] Villarreal-Garza C, Martinez-Cannon BA, Platas A, Mohar A, Partridge AH, Gil-Moran A, et al. Fertility concerns among breast cancer patients in Mexico. Breast 2017; 33: 71-75.

[46] Salama M, Ataman-Millhouse L, Braham M, Berjeb K, Khrouf M, Rodrigues JK, et al. Installing oncofertility programs for common cancers in limited resource settings (Repro-Can-OPEN study): An extrapolation during the global crisis of coronavirus (COVID-19) pandemic. J Assist Reprod Genet 2020; 37(7): 1567-1577.

[47] WorldData.info. Developing countries. [Online] Available from:https://www.worlddata.info/developing-countries.php [Accessed 11th September 2024].

[48] Ojo AS, Lipscombe C, Araoye MO, Akinyemi O. Global uptake of fertility preservation by women undergoing cancer treatment: An unmet need in low to high-income countries. Cancer Epidemiol 2022; 79: 1-9.

[49] Maezawa T, Takae S, Takeuchi H, Takenaka M, Ota K, Horie A, et al. A nationwide survey aimed at establishing an appropriate long-term storage and management system for fertility preserving specimens in Japan. J Adolesc Young Adult Oncol 2023; 12(3): 450-457.

[50] Kyono K, Hashimoto T, Toya M, Koizumi M, Sasaki C, Shibasaki S, et al. A transportation network for human ovarian tissue is indispensable to success for fertility preservation. J Assist Reprod Genet 2017; 34(11): 1469-1474.