Infertility: Taboo and the expansion of medically assisted reproduction in Tunisia

When Alia* got married in 2002, she and her husband were in no rush to have children. She was 30 years old and had never been to a gynecologist. Two years later, she had her first consultation, with a doctor recommended by a relative. The doctor happened to be one of Tunisia’s leading specialists in medically assisted procreation (MAP or ART). Tests revealed polycystic ovaries, a common hormonal condition that can cause complications during pregnancy. The doctor later discovered that Alia also had endometriosis, a chronic disease affecting nearly 10% of women of reproductive age, according to the World Health Organization (WHO). It can be very painful and is still poorly understood by both the general public and healthcare professionals in many countries.

After undergoing surgery and experiencing the spontaneous termination of her first pregnancy, Alia and her husband decided to turn to MAP. The process lasted about ten years, ending without a child but yielding, as Alia reflects at age 53, “a lot of serenity and wisdom” and “a heightened sensitivity to social injustice.”

Tunisia, a well-known destination 

Since the 2000s, with the significant development of infrastructure supporting MAP in Tunisia, the country has become a regional destination recognized for the expertise of its medical personnel serving infertile couples from across the Maghreb, especially Algeria and Libya, as well as sub-Saharan Africa. About a dozen private fertility centers and three public facilities operate nationwide, mainly in the capital and coastal cities such as Sousse, Sfax, and Nabeul, creating geographic inequalities in access.

Practice predated the legal framework. The technologies and know-how were first introduced in the private sector in the 1980s by professionals trained in Europe. In 1989, the first “test-tube baby” was born, and a decade later, in 2001, Tunisia passed a landmark law governing reproductive medicine—one of the first of its kind in Africa and the Arab world, developed in consultation with religious authorities.

The law authorizes the use of MAP procedures, such as artificial insemination with the husband’s sperm and in vitro fertilization (IVF) for married heterosexual couples, while banning gamete donation due to Islamic principles of lineage and filiation. Egg freezing, which allows women to delay motherhood, is permitted for single women only for medical reasons affecting fertility.

Infertility is not considered a public health issue by political authorities in Tunisia, even though it can cause deep suffering and social stigma.

A rise in infertility

Globally, infertility rates are rising—that is, the inability to achieve pregnancy after at least 12 months of attempts. Causes include increasing environmental pollution, reproductive system disorders in both men and women, and increasingly delayed childbearing.

In Tunisia, the average age at marriage is rising: in 2024, it was 35 for men and 29 for women. MAP provides a solution to ensure access to reproductive rights, though not with guaranteed success. Success rates vary considerably depending on the technique and a multitude of factors (age, method, and number of attempts). While there are no national statistics, some clinics make their results public.

Infertility is not considered a public health issue by political authorities in Tunisia, even though it can cause deep suffering and social stigma. In the absence of statistics, it is difficult to estimate the number of couples seeking MAP, but the growth of available services and cross-border mobility signals high demand.

A persistent taboo

In 2018, a transdisciplinary research team explored the issue in a project titled “Cross-border reproductive health care in the Maghreb: A reproductive landscape in the making,” thus filling an academic gap. A collective work containing several scientific articles was subsequently published: Voyager pour procréer au Maghreb. Expériences au sein d’une nouvelle industrie médicale (Traveling to Procreate in the Maghreb: Experiences in a New Medical Industry) (Editions IRMC and Karthala, 2024).

The study identified several reasons couples travel to Tunisia for MAP: lack of equipment in their home countries, excessively long waiting times, geographical proximity, visa exemptions, cost-quality ratio, shared languages (Arabic and French), cultural and religious affinities, and the desire for anonymity and discretion. Many patients choose to keep their experience secret, partly wishing to protect their privacy from intrusive questions and pressure from those around them.

Several fertility specialists interviewed noted that about half of the cases with difficulties in conceiving are related to sexual causes. “In September, just after the wedding season, I receive many patients who come to see me because they are unable to have sexual intercourse. Vaginismus [editor’s note: involuntary contraction of the vaginal opening] is common,” explains gynecologist-obstetrician Olfa Naghmouchi. Early concerns about the inability to get pregnant reflect an urgency to conceive that arises from “both personal desire and social pressure.” She frequently refers her patients to sexologists before discussing MAP.

When infertility is confirmed, the process takes time. “Most couples turn to MAP only as a last resort. It’s a long and costly process. Many husbands refuse. They fear religious or technical issues—some even worry that sperm samples might get mixed up,” she adds.

The question of time 

Marwa*, 42, from Tunis, is currently seeing a gynecologist as part of an MAP procedure. She is being treated by a team at a public hospital, where she says the staff is “very kind.” She and her husband have not told their families for the time being. “During my first pregnancy, I shared the news right away. When it ended, people didn’t know how to support me, which made it harder for me,” she shares. She recalls confiding in a stranger who comforted her. “She told me, ‘May their soul rest in peace.’ Being allowed to speak of the love I felt for this little being helped me heal.”

Pregnancy loss is often downplayed, especially in the context of MAP, where several attempts may be needed. These experiences are silenced and invisibilized. Recently, Marwa made the decision to pause ovarian stimulation to take her time, even though it’s limited. “Nature doesn’t follow our rhythm,” she notes, “but it’s a joyful project we’re carrying forward!”

Public and private treatment alike are only partly covered by Tunisia’s National Health Insurance Fund (CNAM): women over 40 are excluded. For the latter, only lab tests and medications, not medical procedures like IVF, are reimbursed.

The study identified several reasons couples travel to Tunisia for MAP: lack of equipment in their home countries, excessively long waiting times, geographical proximity, visa exemptions, cost-quality ratio, shared languages (Arabic and French), cultural and religious affinities, and the desire for anonymity and discretion.

Women bearing the “weight” of infertility

A director of a leading Tunis clinic notes that patients come from varied socioeconomic backgrounds; poorer couples often collect money from others or go into serious debt. And while MAP can strengthen some marriages, another social consequence mentioned by several interviewees is divorce. Divorce is much more frequently requested by men, sometimes under family pressure.

Gender norms and social expectations around motherhood deeply shape MAP experiences. The inability to conceive carries stigma, usually borne by women. “What clearly emerges, not only in Tunisia but across the Maghreb, is that women carry the social burden, even when infertility originates with the man. They won’t publicly say it’s their husband; it’s unthinkable,” explains Irène Maffi, professor of anthropology, the co-editor with geographer Betty Rouland of Voyager pour procréer au Maghreb.

Reproductive power is culturally tied to both masculinity and femininity, but women bear most of the blame for infertility. Tunisian and foreign women are usually the ones to initiate the process and often attend consultations alone. “Only after the woman’s tests and analyses does the man get involved. Health professionals note that when infertility stems from the man, some never return to the clinic and absolutely refuse to acknowledge it,” the researcher continues.