Infertility is defined by the World Health Organization (WHO) as the inability for a couple to conceive after 12 months of regular, unprotected sexual intercourse [1] . It is estimated to affect approximately 48 million couples and 186 million individuals worldwide [2] . Its prevalence is relatively stable in industrialized countries (8% - 12%) [3] , but much higher in low- and middle-income countries, sometimes reaching 25% - 30% in sub-Saharan Africa [4] [5] . In Cameroon, several recent studies report a prevalence between 20 and 30% [6] [7] . In most cases, it is secondary infertility, often linked to a history of sexually transmitted infections (STIs), induced abortions in precarious conditions, or surgical complications [7] [8] . These observations align with those described in other African countries, where infectious causes are more prevalent compared to genetic or endocrine etiologies more commonly observed in Western countries [4] [9] . Beyond the biomedical aspect, infertility represents a considerable psychosocial suffering. In African societies where motherhood is a key factor of identity and social recognition, the absence of children can expose a woman to stigma, marital tensions, isolation, and even polygamy or divorce [10] - [12] . This emotional burden, long underestimated, is now recognized as a central element of the infertility experience [13] . To incorporate this dimension, the assessment of quality of life (QoL) has become an essential tool. The FertiQoL (Fertility Quality of Life) questionnaire, developed by Boivin et al. in 2011 [14] , is the international reference tool, validated and widely used in various contexts. It explores four dimensions: emotional, social, relational, and body/mind. However, its use remains rare in Africa, and no study had yet assessed the QoL of infertile women in Cameroon using this instrument. In this context, we conducted a study aimed at evaluating the quality of life of infertile women in Douala using the FertiQoL score. Our objectives were to identify the determinants associated with the alteration of the different dimensions and to evaluate the impact of infertility on the QoL of infertile women in Douala, in order to contribute to a better understanding and management of infertility in the Cameroonian context.

In our study population, infertility is associated with a measurable deterioration in quality of life (QoL) as evaluated by FertiQoL, with notable independent determinants: history of STIs (OR = 3.6), being single (OR = 1.6), income < 100,000 FCFA (OR = 1.5), nulliparity (OR = 1.3), and infertility duration >20 years (OR = 1.5). These associations align with regional and global data: in East Africa (Zanzibar), FertiQoL decreases with the duration of infertility and certain clinical factors; in Ethiopia, infertile women exhibit significantly lower QoL scores than fertile controls, and a history of STIs is linked to lower QoL; in Nigeria, recent comparisons confirm marked deficits in psychological and social domains among infertile women compared to controls [15] - [17] .

Our findings on marital status fit within pro-natalist contexts where marriage remains a key source of material and emotional support. The stigma of infertility documented in Ghana and summarized in a systematic review degrades QoL through social isolation and avoidance coping strategies; being single may amplify this risk by reducing access to marital and family support [6] [9] . This sheds light on the independent contribution of single status to the observed low QoL.

Economic precarity (income < 100,000 FCFA) as a predictor of low QoL is consistent with the financial burden of fertility treatments: the WHO notes that 1 in 6 people will face infertility during their lifetime, and costs, often paid out-of-pocket, expose households to catastrophic expenditures, particularly in low- or middle-income countries. In such contexts, financial constraints can exacerbate anxiety, delay treatment, and ultimately lower QoL [18] .

Regarding the type/duration of infertility, our data (nulliparity and duration > 20 years associated with lower QoL) align with African and international work showing: (i) differences in QoL between primary and secondary infertility (with sometimes less impaired QoL in women who have already given birth), (ii) a gradual decrease in FertiQoL with repeated treatment cycles and prolonged therapeutic journeys [3] [7] [10] . These heterogeneities (e.g., Zanzibar vs. Nigeria) highlight the influence of local social norms and past maternity experiences on the perception of QoL.

Instrumentally and culturally, the use of FertiQoL remains relevant (an internationally validated tool), but recent work in North Africa emphasizes the importance of a culturally sensitive interpretation of scores: some social dimensions poorly capture the specific social pressure in collectivist societies, suggesting needs for contextual adaptations and interpretive support [2] [19] .

1. Integrate systematic psychosocial screening (FertiQoL + anxiety-depression screening) into infertility consultations, with referral to psychological support and peer groups to counteract stigma and isolation [13] [20] .

2. Reduce financial barriers: advocate for partial public/insurance funding of care (imaging, surgery, medical assisted reproduction) in line with WHO calls to limit catastrophic expenditures [18] .

3. Proactively prevent and treat STIs (standardized screening/treatment) given their strong association with degraded QoL [6] .

4. Couple/family-centered approach: interventions considering marital status and duration of infertility; therapeutic education on realistic expectations and non-avoidant coping strategies [6] [7] [9] .

5. Cultural adaptation of FertiQoL: train teams to interpret local social domains and consider complementary modules (e.g., financial burden), as suggested by Sudanese experience [1] [19] .

This study adds local evidence on modifiable levers (STIs, financial constraints, isolation), but its cross-sectional design limits causal inference; a longitudinal cohort and trials of psycho-educational/financial interventions will allow testing the improvement of FertiQoL and its domains. The socio-cultural nuances also call for ongoing contextual validation of FertiQoL.

This study, the first of its kind in Cameroon using the FertiQoL score, highlights the considerable impact of infertility on the quality of life of women in Douala. More than one in two participants had impaired quality of life, with predominant effects on the emotional, social, and body/mind dimensions, while the relational dimension seemed relatively preserved. The main determinants of diminished quality of life were being single, low income, history of sexually transmitted infections, nulliparity, and prolonged duration of infertility. These factors reflect the particular vulnerability of exposed women, where the absence of children represents not only a medical suffering but also a social and identity-related impact. Beyond the epidemiological findings, this study advocates for a holistic and multidisciplinary approach to infertility care in Cameroon, including: the prevention of genital infections and risky abortions; improvement of financial and geographical accessibility to reproductive care; and, most importantly, systematic psychological support for patients, in order to reduce the associated emotional and social distress.

All authors contributed to the development of this work.