The results of this study indicate that knowledge about infertility is limited in the study population. For instance, more than half of the participants were misinformed that use of IUCD and OCPs may lead to infertility. The most interesting finding of this study was that the majority of individuals would prefer alternative treatment options, if unsuccessful with the allopathic medicine. Also, half of the participants considered a "test tube baby" an unacceptable option, despite its acceptability by religious dictums. Another significant finding regarding perception of infertility was subjects' beliefs in the evil forces and supernatural powers as a cause of infertility, which correlated with their education level.
The inadequacy of knowledge about infertility was clearly demonstrated through this study. This lack of knowledge explains why such a strong stigma is attached to infertility in the society. The results of this study are similar to that of a large global survey conducted during the World Fertility Awareness Month (2006) on approximately 17,500 individuals, which revealed that the knowledge regarding fertility and biology of reproduction was lacking throughout the world . The limited knowledge was further confirmed upon discovering that merely one-fourth of the participants knew how infertility is diagnosed after at least two years of regular unprotected sex. This may subsequently determine when the couple will start seeking treatment, which should be neither premature nor delayed. It is also important for the elderly in the society to have some awareness about infertility. In that way, they will not pressurize young newlyweds, if they are unable to conceive right after the marriage, which is a common expectation in the joint family structure in Pakistan.
In addition to proper knowledge about infertility, it is also crucial to know the most fertile period for a woman when she is trying to conceive. One of the surprising results found in this study was that only 46% of the participants correctly identified mid-cycle as the most fertile period during the female's menstrual cycle. The lack of accurate information in this case may lead to improper timings of sexual intercourse, thus possibly delaying the pregnancy.
While testing the subjects' knowledge, we also assessed what they considered to be the causes of infertility. Although it is not important that the general public know all the causes, it is important for them to know about acquired and potentially preventable causes of infertility such as sexually transmitted diseases. The participants in this study correctly identified most of the causes of infertility but also incorrectly highlighted factors that do not cause infertility such as use of IUCD and OCP. This may lead to underutilization of contraception for incorrect fear that the method will cause sterility and contribute to the already high rates of parity in the developing countries. These results are supported by another study conducted by Bunting .
While the limited knowledge about infertility was an important discovery, the most interesting finding was about people's attitude towards infertility. Though majority of the participants believe that the couple should seek treatment, not all of them would seek allopathic practitioners and instead would seek alternative treatments. In this study, it was noted that alternative medicine options, such as visiting Hakeems (15%) and pirs (faith healers) (13%) were considered acceptable. This reflects prevalence of the strong belief that all ailments cannot be cured by medical science.
Another interesting finding of this study was the correlation between beliefs in evil forces or supernatural powers as causes of infertility and the education level of the subjects. Some respondents (30%) believed that if the female is not able to conceive, she may be possessed by an evil spirit. The less educated participants were more likely to attribute the causes of infertility to an evil force or supernatural power, outside human control. In fact, these findings are confirmed by another study which was conducted amongst the Kuwati infertile women. It was discovered in that study that the uneducated group attributed the causes of their infertility to supernatural causes such as evil spirits, witchcraft and God's retribution, while the educated group held nutrition, marital and psychosexual factors responsible for their infertility .
In order to consider all these perceptions in a proper light, it is important to consider the societal norms and culture of Pakistan. In this part of the world, it is usually the woman who is being blamed for infertility as a reaction to a couple without children, which was confirmed through the study. Another study conducted by Sami et al. in Pakistan revealed that 69% of the secondarily infertile women reported being blamed for infertility often by in-laws, followed by husbands (38%) . She further reported that one third of the women were blamed to be unlucky not only to the husbands but also to the entire family. The placement of unnecessary blame on a woman can potentially affect her self-esteem and become socially crippling for her.
As a result of the improper blame placed on a woman, infertility can be a common cause of marital discordance between couples. This issue was addressed by asking the subjects their views on divorce and husbands' remarrying in case of infertility. It was disturbing to discover that people believe husbands should be allowed to remarry and have a second wife in case he is not able to conceive with the previous wife. According to Islam, the religion of majority of Pakistan, infertility is not a ground for divorce for either the male or the female. Yet this study showed that people were still in favor of divorce. This implies disconnection between people's religious beliefs and their beliefs about infertility.
Despite the disconnection, religion and customs continue to play a major role in the practices related to infertility. Hence, it makes sense that knowledge about treatment option for infertility, such as IVF, is very low because it is an advanced option with limited availability in Pakistan. Amongst the respondents who knew about it, 55% considered it unacceptable because of beliefs that it's not allowed in Islam or that the procedure may use foreign egg or sperm. This reveals that even the small group of people that knew about IVF is misinformed. Individuals may not be aware that IVF and similar technologies are permissible in Islam as long as they do not involve any form of third-party donation [24, 25]. While IVF has been explored in other Islamic countries such as Iran, this issue needs further exploration and active debate in Pakistan.