This study provides key insights into the context and challenges that determine exercise behaviour among women with infertility. To the best of our knowledge, this is the first study from South Asia to explore the perception of health and exercises among women with infertility.

Participants in our research reported obesity and altered lifestyle as major factors for infertility. It was believed to cause irregularity of menstruation and affect fertility. A previous survey conducted among women with infertility reported that 82.7% of the participants considered obesity to increase the chances of infertility.25 Obesity alters the hypothalamic-pituitary-ovarian axis causing ovulatory dysfunctions and oocyte impairments, thus affecting reproduction.26

Participants in this study reported that their current physical activity levels are lower, compared to previous generations, and this could be a major reason for infertility. They believed that mechanization has reduced manual efforts resulting in obesity and in turn, increased the rate of infertility among women. Participants in a previous study on their perceived barriers and facilitators to physical activity have reported similar findings.27 However there was a lack of awareness among our participants about the recommended level of physical activity as per the guidelines.13 Reasons for infertility in women may be due to ovarian, tubal, or uterine causes, but sometimes, the cause remains unknown.28 However, our participants were not aware of the other causes of female infertility. The primary causes of infertility among 10 of our participants were male-related causes such as reduced sperm count, poor quality of sperm etc. However, the women blamed themselves for infertility. It has been reported that in Indian society, childbearing is considered necessary,29 and infertility is considered a woman's problem, thus she is blamed for not being able to procreate.30 This implies the necessity to spread awareness about the causes of infertility among the general population so that necessary measures can be taken based on the root causes rather than only “blaming” the women for the primary reason for infertility.

Only a few participants in our study believed that they must remain physically active before or while undergoing the procedures to conceive. Our findings contradict the results of a previous study which reported that the majority of participants preferred to exercise during IVF.31 Most of our participants believed that exercise during the procedure would impair fertilization and prevent pregnancy. Similar to our findings, participants from a previous study believed that there would be a negative effect on the outcome of their treatment if they did not limit their physical activity.32 A previous study has reported that there is no positive or negative association of physical activity with pregnancy outcomes in fresh embryo transfers, including during the critical period of embryo implantation.33

Our participants had a misconception that they must not do exercise and must rest during menstruation to maintain good health and prevent dysmenorrhea as advised by elders in the family. A previous study has reported the benefits of exercise during menstruation on physical and mental health.34 However, previous literature has reported that intense exercises can result in low energy availability which leads to reduced luteinizing hormone, which diminishes ovarian stimulation and estradiol production leading to menstrual disorders. Hence avoiding high-intensity exercises during menstruation may be beneficial.35

In our study, we found that social media, doctors, and family members were the sources of information for knowledge about the effects of exercise. A UK-based study has reported that information obtained from the health care providers was insufficient and hence, additional information was sought by the participants from the internet and other consultants.36 Another study reported that people preferred to collect information from reliable hospital sites on the internet as they found it embarrassing to indulge in a face-to-face discussion about fertility-related issues with doctors.37 However, participants sought information from the internet about infertility, its causes, and treatment methods but not regarding physical activity or exercise recommendations. This brings out an important lacuna in the dispersion of knowledge about the role of physical activity and exercises in this population by physical therapists. Spreading awareness about the role of physical therapy and appropriate physical therapist referrals of these women by practicing gynecologists may result in better patient outcomes.

Our participants who exercised followed low to moderate-intensity exercises. However, the overweight participants in our study did not follow the recommended guidelines for weight loss which include 250 min of moderate-intensity walking or activity for weight loss.38 Despite being in the normal BMI category, most of our participants were motivated to exercise as they were aware of other health benefits of exercise including psychological well-being. The benefits of exercise on mental health have been reported in previous literature.39

The preferred types of exercise by participants in the current study were brisk walking and yoga. To the best of our knowledge, no previous studies have reported exercise behaviours and preferences in women with infertility. Previous systematic reviews have reported the benefits of yoga in reducing BMI in overweight, obese, or individuals with metabolic syndrome.40,41 An Indian study has reported that both walking and yoga were preferred exercises by their participants.36 Similar activity preferences were reported by studies done in other populations.42–45

Our study participants reported support and help from family, availability of open spaces and knowledge about the health benefits of exercise as facilitators to exercise. They also reported that their families would help and encourage them to make decisions on their own. Previous literature about physical activity perceptions of women in Ghana also reported knowledge about health benefits as a facilitator to exercise.46

In our study, lack of family support, time, motivation to exercise, and inquisitive behaviour of neighbours/relatives were reported as barriers to exercise by the participants. Some participants mentioned laziness and lack of interest as reasons for not exercising. Previous literature has reported a lack of willpower, lack of money, lack of social acceptance of walking and feeling shy/embarrassed, and unavailability of facilities as barriers to exercise, in addition to those identified in our research.36,46

The results indicate that obesity and altered lifestyle are perceived as major causes of infertility. Women often sought information about exercises from social media, doctors, and family members. Most women were willing to exercise if advised by doctors and the preferred types of exercises were brisk walking and yoga. Supportive families and the availability of facilities were the main facilitators for exercise practice. Common barriers to exercise were lack of awareness, lack of time and motivation, and lack of family support.