Pattern of infertility among infertile couples in a tertiary health institution in Bayelsa State, South-South Nigeria

INTRODUCTION

Infertility is defined as the inability of a cohabiting couple to conceive after one year of adequate and regular unprotected, peno-vaginal sexual intercourse.¹ Globally, infertility affects 8%–15% of couples.^2,3 Thirty percent of cases are solely attributable to a male factor, 30% to female factors, and combined male and female factors in up to 30%; others are unexplained.^4–6 The most common reversible cause of male factor infertility is varicocele.⁴ The most common causes of female infertility include anovulation (polycystic ovary syndrome being the most common cause), tubal disease, pelvic adhesions, and endometrisosis.⁷

Primary infertility is when a couple has never conceived despite 12 months or more of adequate unprotected sexual intercourse, whereas in secondary infertility, the couple has previously conceived, but is subsequently unable to conceive despite adequate unprotected sexual intercourse for at least 12 months.⁸ Women in developed countries tend to suffer primary infertility predominantly. In contrast, higher rates of secondary infertility are seen in developing countries, reflecting the high prevalence of tubal disease from sexually transmitted, post-abortion and puerperal infections in these countries, the most commonly implicated organisms being Chlamydia trachomatis and Neisseria gonorrhoeae.^9–11

The woman’s age is the single most important factor influencing a couple’s ability to conceive.¹² Female fertility begins to decline after 30 years of age, drops quite rapidly after 35 years, and precipitously declines after 40 years, owing to a decline in both the quantity and quality of ovarian follicles.^4,12,13 A World Health Organization (WHO) Study of over 5,800 couples in 33 centres in 25 countries, revealed that whereas 42% of infertile women in developing countries were 24 years or younger, this age range represented only 25% of infertile women in developed countries.¹¹ This is explained by the fact that whereas more women in the developed world are delaying childbearing for various reasons including career, the world’s highest total fertility rates are found in Africa and other developing regions, where early marriages are common, and there is little voluntary effort to postpone childbearing.⁹

The World Health Organization (WHO) Study also found that whereas nearly one-half of couples in developed countries sought medical evaluation within less than two years of infertility, over two-thirds of those in developing countries presented after more than 2.5 years of infertility.¹¹ Infertile women in developing countries often first wait passively, consult general practitioners, or patronize alternative/unorthodox medicine providers, before seeking specialist care for infertility.¹⁴ This study sought to evaluate the pattern of infertility among infertile couples at the Federal Medical Centre, Yenagoa, in Bayelsa State, South-South Nigeria.

METHODS

A retrospective, descriptive, cross-sectional study of infertile couples seen at the Infertility Clinic of the Federal Medical Centre, Yenagoa, Bayelsa State, Nigeria, was conducted. Case records of all the infertile couples that presented to the Infertility Clinic for evaluation, from January to December, 2021, were retrieved, and relevant data, which included age, religion, level of education, State of residence, occupation, parity, number of children alive, age at menarche, type of infertility, duration of marriage, duration of infertility and causes of infertility, were extracted from the case records using a pre-designed proforma, for data analysis. Patients that presented with complaints other than inability to conceive were excluded from the study.

Investigations requested included hormone profile, hysterosalpingography, transvaginal ultrasound scan and seminal fluid analysis. Hormone profile (day 3 prolactin, follicle stimulating hormone, luteinizing hormone, oestrogen, testosterone and day 21 progesterone) was used to assess ovarian reserve, and confirm ovulation. Thyroid function tests were done when there was clinical suspicion of thyroid disease. Hysterosalpingography was used to assess for tubal pathologies and intrauterine adhesions, while transvaginal ultrasound scan was used to assess for polycystic ovaries, endometrial plate, leiomyoma and other pelvic pathologies. Seminal fluid analysis was used to assess for male factor infertility, using the World Health Organisation 2010 criteria.¹⁵ Treatment was based on results of at least two seminal fluid analyses done at least four weeks apart.

Collected data were analysed using Statistical Product and Service Solutions for Windows® version 25 (SPSS Inc.; Chicago, USA). Analysis of categorical variables was presented in frequencies and percentages, while analysis of continuous variables was presented in mean and standard deviation.

Ethical approval for this study was obtained from the Hospital’s Ethics and Research Committee.

RESULTS

Sociodemographic characteristics of infertile women

Within the study period, 187 couples were evaluated for infertility, out of 1,027 gynaecological patients, giving an infertility incidence rate of 18.2%. The mean age of the women was 33.7±5.9 years, with a modal (55, 29.4%) age group of 26-30 years. Majority of the women were Christians (184, 98.4%), who resided in Bayelsa State (170, 90.9%). Eighty-seven (46.5%) and 84 (44.9%) of the women had secondary and tertiary level education, respectively. Most of the women were traders (77, 41.2%); others were civil servants (41, 21.9%), and professionals (16, 8.6%), while 42 (22.5%) of the women were unemployed. The mean duration of marriage was 5.5±3.9 years. These sociodemographic characteristics are shown in Table 1.

Gynaecological characteristics of infertile women

The parity of the women ranged between 0 and 4, with a median of 0. Most (100, 53.5%) of the women were nulliparous. The mean age at menarche of the women was 13.3±1.5 years. Secondary infertility (151, 80.7%) was the predominant type of infertility, with most (148, 79.1%) of the women having a duration of infertility of 1-5 years (Table 2).

Aetiology of infertility

Tubal factor was the most common (104, 55.6%) cause of infertility. The most common tubal factor was tubal blockage (92, 49.2%). Male, uterine, and ovarian factors were responsible for infertility in 81 (43.3), 63 (33.7%), and 58 (31.0%) women, respectively. Intrauterine adhesion was present in 20 (10.7%) women.

Uterine fibroids (in combination with other factors) were seen in 41 (21.9%) women, but solely, they were seen in 14 (7.5%) of the women. Polycystic ovary syndrome (21, 11.2%), ovarian insufficiency (19, 10.2%), and hyperprolactinaemia (18, 9.6%) were the identified ovarian factors.

Overall, female factor infertility was present in 146 (78.1%) of the women. However, female factor alone was responsible for infertility in 101 (54.0%) of cases, while male factor alone was identified in 36 (19.2%) cases. A combination of male and female factors was identified in 45 (24.1%) couples. The cause of infertility was unexplained in 5 (2.7%) couples (Tables 3 and 4).

*Multiple aetiologies in some couples, hence n>187.

DISCUSSION

Infertility is a major health condition globally. The incidence varies widely from one region to another, and it is highest in the infertility belt of Africa, of which Nigeria is part.¹⁶ Our study revealed an infertility incidence rate of 18.2%, which was similar to the 18.5% reported by Nwajiaku et al in Nnewi.¹⁷ It was higher than the 15.4% and 12.1%, respectively reported by Obuna et al and Menuba et al both in South-East Nigeria, but lower than the 32.0% reported by Odunvbun et al in South-South Nigeria, 26.8% by Adegbola and Akindele in South-West Nigeria and 23.9% by Dattijo et al in Bauchi, Northern Nigeria. Worldwide, infertility affects 8-15% of couples.^{2,3,14,18,19,21} The differences in rates may be related to the sociocultural differences, differences in health-seeking behaviour and genetic makeup of the people residing in the various regions of the world.²²

The mean age of the women in this study was similar to those reported by Odunvbun et al in South-South Nigeria and Adegbola and Akindele in South-West Nigeria, but higher than the mean reported by Dattijo et al in Bauchi, Northern Nigeria.^14,20,21 This is a reflection of the lower age at marriage that is prevalent in Northern Nigeria. A plausible reason for the age distribution in our study may be due to the fact that many women in our environment have preference for alternative/non-medical care, which includes visit to traditional birth attendants, prayer houses, maternity homes, and other non-orthodox places, before presenting to a specialist for expert care. The ability to conceive declines with increasing age. Factors that may reduce fecundity, such as tubal disease, uterine fibroids, endometriosis and male factor infertility, increase with age. A reduction in coital frequency with increasing age also plays a role.²³ At about 28-30 weeks’ gestational age, ovarian follicles are about 7 million. They reduce to 2 million at birth, and then 500,000 at puberty, and continue to decline with age until menopause.

In this study, the most common type of infertility was secondary, and this finding corroborates the reports of many other authors.^{19–21,24–28} A plausible explanation for this may be due to post-abortion sepsis and pelvic inflammatory diseases, that may have complicated previous induced abortions. Sexually transmitted infections, post-operative/procedure infections, and puerperal sepsis from previous deliveries supervised by unskilled/traditional birth attendants, which is very common in our environment, may be other plausible reasons for the high proportion of women with secondary infertility in our study.

The mean duration of infertility in our study was 3.9±3.6 years. This was lower than the 5±3 years reported by Odunvbun et al., 4.3±3.4 years reported by Adegbola and Akindele, and 4.1±3 years reported by Ekwere et al.^14,20,29 The duration of infertility and duration of marriage often positively correlate with the age of the woman, as increasing age is associated with a high rate of infertility. The incidence of male factor infertility in our study was 43.3%, which is lower than the 56% reported by Odunvbun et al but higher than the 34.5% reported by Ekwere et al 38.2% reported by Tabong and Adongo, 19.7% reported by Panti and Sununu, and 17.7% reported by Dattijo et al.^20,21,29-31 A wide range of aetiological factors (pre-testicular, testicular and post-testicular) are known to cause male infertility.

Tubal blockage was the commonest (49.2%) cause of infertility in this study. This value was higher than the 42% reported by Odunvbun et al and 63.6% reported by Panti and Sununu.^20,31 Post-abortion sepsis, pelvic inflammatory disease, sexually transmitted infections and puerperal sepsis due to poor health-seeking behaviour of the women in our environment are largely responsible for the high incidence of tubal factor infertility. Uterine factor contributed 33.7% to infertility in our study. Intrauterine adhesions usually arise from overzealous curettage (during intrauterine procedures and unsafe abortion) and endometritis (from post-abortion/puerperal sepsis). Solely, uterine fibroids were present in 7.5% of the infertile women in this study. Uterine fibroid is not a usual cause of infertility. In fact, the role of uterine fibroids in the aetiology of infertility is more of casual than causal.³² This means that the presence of uterine fibroid is only attributed to infertility when no other cause can be found.

The pattern of contribution of various aetiological factors to infertility in our study was different from those earlier reported from within and outside Nigeria.^4–6,20,33 These variations may have resulted from sociocultural differences, differences in health-seeking behaviour, exposure to environmental toxins which may predispose to infertility, sexually transmitted infections, environmental factors like stress which may inhibit ovulation.

A limitation of this study is that being a single hospital facility-based study, the findings may not be generalizable. We recommend a larger, highly powered, population-based study, as this will be more representative of the findings in the general population.

CONCLUSION

Our study revealed an infertility incidence rate of 18.2%, which is similar to those reported by other studies in our region. To reduce the incidence of infertility, social reorientation to improve sociocultural practices and the poor health-seeking behaviour of couples, should be pursued vigorously.

ACKNOWLEDGEMENTS

We appreciate all the members of staff of our institution’s medical records department for the roles they played in making this research successful. Dr. Adedotun Daniel Adesina is also appreciated for analysing the data for this study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

REFERENCES

1. 1. Schankath AC, Fasching N, Urech-Ruh C, Hohl MK, Kubik-Huch RA. Hysterosalpingography in the workup of female infertility: indications, technique and diagnostic findings. Insig Imag. 2012;3(5):475-83.
2. 2. Li J, Ren L, Li M, Yang C, Chen J, Chen Q. Screening of Potential Key Genes Related to Tubal Factor Infertility Based on Competitive Endogenous RNA Network. Genet Test Mol Biomark. 2021;25(5):325-33.
3. 3. Inhorn MC, Patrizio P. Infertility around the globe: new thinking on gender, reproductive technologies and global movements in the 21st century. Hum Reprod Update. 2015;21(4):411-26.
4. 4. Benbella A, Aboulmakarim S, Hardizi H, Zaidouni A, Bezad R. Infertility in the Moroccan population: an etiological study in the reproductive health centre in Rabat. Pan Afr Med J. 2018;30(204).
5. 5. Brugh VM, Lipshultz LI. Male factor infertility: evaluation and management. Med Clin North Am. 2004;88(2):367-85.
6. 6. Eisenberg ML, Lathi RB, Baker VL, Westphal LM, Milki AA, Nangia AK. Frequency of the male infertility evaluation: data from the national survey of family growth. J Urol. 2013;189(3):1030-4.
7. 7. Barbieri RL. Female infertility. In: Yen and Jaffe’s Reproductive Endocrinology. Netherlands: Elseiver. 2019;556-81.
8. 8. Jeje EA, Alabi TO, Ojewola RW, Ogunjimi MA, Osunkoya SA. Male infertility: An audit of 70 cases in a single centre. Afr J Urol. 2016;22(3):223-6.
9. 9. Nachtigall RD. International disparities in access to infertility services. Fertil Steril. 2006;85(4):871-5.
10. 10. Orhue A, Aziken M. Experience with a comprehensive university hospital-based infertility program in Nigeria. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 2008;101(1):11-5.
11. 11. Cates W, Farley TM, Rowe PJ. Worldwide patterns of infertility: is Africa different? Lancet Lond Engl. 1985;2(8455):596-8.
12. 12. Balasch J. Ageing and infertility: an overview. Gynecol Endocrinol Off J Int Soc Gynecol Endocrinol. 2010;26(12):855-60.
13. 13. Vander Borght M, Wyns C. Fertility and infertility: Definition and epidemiology. Clin Biochem. 2018;62:2-10.
14. 14. Adegbola O, Akindele MO. The pattern and challenges of infertility management in Lagos, Nigeria. Afr Health Sci. 2013;13(4):1126-9.
15. 15. World Health Organization. WHO laboratory manual for the examination and processing of human semen [Internet]. 5th ed. Geneva, Switzerland: World Health Organization Press. 2010;7-113.
16. 16. Agarwal A, Mulgund A, Hamada A, Chyatte MR. A unique view on male infertility around the globe. Reprod Biol Endocrinol RBE. 2015;13:37.
17. 17. Nwajiaku LA, Mbachu II, Ikeako L. Prevalence, Clinical Pattern and Major Causes of Male Infertility in Nnewi, South East Nigeria: A Five YearReview. Afrimedic J. 2012;3(2):16-9.
18. 18. Obuna JA, Ndukwe EO, Ugboma HAA, Ejikeme BN, Ugboma EW. Clinical Presentation of Infertility in an Outpatient Clinic of a Resource Poor Setting, South-East Nigeria. Int J Trop Dis Health. 2012;2(2):123-31.
19. 19. Menuba IE, Ugwu EO, Obi SN, Lawani LO, Onwuka CI. Clinical management and therapeutic outcome of infertile couples in southeast Nigeria. Ther Clin Risk Manag. 2014;10:763-8.
20. 20. Odunvbun WO, Oziga DV, Oyeye LO, Ojeogwu CL. Pattern of infertility among infertile couple in a secondary health facility in Delta State, South South Nigeria. Trop J Obstet Gynaecol. 2018;35(3):244-8.
21. 21. Dattijo LM, Andreadis N, Aminu BM, Umar NI, Black KI. The prevalence and clinical pattern of infertility in Bauchi, northern Nigeria. Trop J Obstet Gynaecol. 2016;33(1):76-85.
22. 22. Ombelet W, Cooke I, Dyer S, Serour G, Devroey P. Infertility and the provision of infertility medical services in developing countries. Hum Reprod Update. 2008;14(6):605-21.
23. 23. American College of Obstetricians and Gynecologists Committee on Gynecologic Practice and Practice Committee. Female age-related fertility decline. Committee Opinion No. 589. Fertil Steril. 2014;101(3):633-4.
24. 24. Olatunji AA, Jagun OE, Toyobo OO, Ashaolu OA, Adekoya OA. Hysterosalpingogram findings among women with infertility in Ogun State, Nigeria. Ann Health Res. 2017;3(2):75-81.
25. 25. Kiridi EK, Oriji PC, Ugwoegbu JU, Abasi IJ. Hysterosalpingography Findings among Women Presenting for Infertility Evaluation in Bayelsa State, South-South Nigeria. J Adv Med Med Res. 2022;34(5):7-17.
26. 26. Kiridi EK, Oriji PC, Abasi IJ, Ubom AE, Ugwoegbu JU. Predictors or abnormal findings in infertile women undergoing hysterosalgography in Bayelsa State, South-South Nigeria. Int J Clin Obstet Gynaecol. 2022;6(2):22-30.
27. 27. Makwe CC, Ugwu AO, Sunmonu OH, Yusuf-Awesu SA, Ani-Ugwu NK, Olumakinwa OE. Hysterosalpingography findings of female partners of infertile couple attending fertility clinic at Lagos University Teaching Hospital. Pan Afr Med J. 2021;40:223.
28. 28. Udobi S, Aronu M. Hysterosalpingographic findings in women with infertility in Awka, Anambra State, South-East Nigeria. Niger J Surg Sci. 2017;27(2):47-7.
29. 29. Ekwere P, Archibong E, Bassey E, Ekabua J, Ekanem IO, Feyi-Waboso P. Infertility among Nigerian couples as seen in Calabar. P H Med J. 2007;2(1):35-40.
30. 30. Tabong PTN, Adongo PB. Understanding the Social Meaning of Infertility and Childbearing: A Qualitative Study of the Perception of Childbearing and Childlessness in Northern Ghana. Plos One. 2013;8(1):e54429.
31. 31. Panti AA, Sununu YT. The profile of infertility in a teaching Hospital in North West Nigeria. Sahel Med J. 2014;17(1):7-11.
32. 32. Oriji PC, Kiridi EK, Allagoa DO, Omietimi JE, Orisabinone IB, Makinde OI. The use of NAAT-PCR to determine asymptomatic chlamydia and gonorrhoea infections in infertile patients undergoing hysterosalpingogram at the federal medical centre, Yenagoa, South-South Nigeria. Int J Reprod Contracept Obstet Gynecol. 2020;9(4):1507-14.
33. 33. Raine‐Fenning N. Subfertility. In: Edmonds DK, Lees C, Bourne T, editors. Dewhurst’s Textbook of Obstetrics & Gynaecology. 9th ed. Oxford, UK: John Wiley & Sons Ltd. 2018;691-703.