{"paper_id":"028c9149-056c-47fb-9982-58cfc0a643c3","body_text":"Infertility is a public health problem during the re.\nproductive age, affecting about 10-15% of couplesattempting to achieve pregnancy in worldwide ( 1 ).\nInfertility is defined by the failure to achieve a natu.\nral pregnancy after 12 months or more of regular un.\nprotected sexual intercourse ( 2 ). For many couples,\nthe inability to bear children is a shocking tragedyleading to serious physical, social, psychological andsexual dysfunction in their lives ( 3 ).\nAccording to World Health Organization (WHO),\nthe term primary infertility is used when a womanhas never conceived and secondary infertility is theincapability to conceive in a couple who have had atleast one successful conception in the past ( 4 ). Infertility can be attributed to anomalies associated witheither male or female reproductive systems or withboth partners. Several factors can disturb the process \nof fertility at any step. For example, female infertilitymay be due to one or more reasons such as, polycysticovary syndrome ( 5 ), hormonal disorders ( 6 ), premature ovarian failure ( 7 ), genital infections ( 8 ), endo.\nmetriosis ( 9 ), fallopian tube obstruction ( 10 ), congenital uterine anomalies ( 11 ), uterine synechiae ( 12 ),\nor other medical complications (diabetes and thyroiddisorders) ( 13 - 14 ).\nNevertheless, male infertility is due to hormonal imbalances,\nand sperm abnormalities ( 3 - 15 ). Other main\ncauses of infertility could be age of a couple ( 16 ), occupation,\nand socio-economic status ( 17 ). Few studies\nwere dedicated to determine the prevalence and associated\nrisk factors for infertility in Morocco. Therefore,\nour aim was to determine the difference between\nprimary and secondary infertilities and to better understand\nthe main infertility associated factors in the\nMoroccan population.\n\nThis cross-sectional study was conducted with the approval \nof the Ethic of the Moroccan health authorities in the region \nof Marrakech-Safi. This region is located in the middle of \nMorocco and consists of one state and eight administrative \nprovinces. This study was conducted at different public and \nprivate health centers in the region of Marrakech-Safi. A sample \nof 619 infertile women referring to these health centers \nwas selected by a simple random sampling method, between \n1 October 2013 and 31 December 2015. The subjects were \nchosen without any previous appointments.\nThe study protocol was explained and the informed consent \nwas obtained from all participants before enrolment. In \nthis study, all data was collected through a questionnaire and \nthe information provided by health booklets for each married \nwoman who had difficulty becoming a mother after at least 12 \nmonths of regular unprotected sexual intercourse. The questionnaire \ncontained different elements: socio-economic data, \ndemographic characteristics, age of the couple, and their nutritional \nstatus. Also, searching health booklets provided history \nand clinical information [urogenital infections, medical complications, \ndiabetes, thyroidism, menstrual disorders, polycystic \novary syndrome (PCOS), tubal dysfunction, varicocele and \ncongenital uterine anomalies] and methods of diagnosis, particularly \nthe results of ultrasounds, hysterosalpingographies, \nhysteroscopies, hormone levels and semen analyses.\nOther data associated with male and female reproductive \norgans were included such as menstruation disorders, uterine \nmalformations, hormonal imbalances, varicocele, the quality \nof sperms, and other medical complications.\nThe subjects who had met our inclusion criteria were married \nwomen during their childbearing ages, who had referred \nto health centers for infertility problems after 12 months of \ntrying for pregnancy. Prior to this research study, the collection \ntool was tested with a pilot group of women similar to \nthose wishing to participate voluntarily in this survey. All \nwomen were entered into the study and their associated data \nwas collected by trained research nursing students.\nA one-sample Kolmogorov-Smirnov test was used to analyze \nnormality for continuous variables. A Chi-square test and \nFisher’s exact test were used for categorical variables.\nStudent’s t test was used to estimate the observed differences \nbetween the means. The multivariate data analysis was \nused to allow for the elimination of the confounding factors \nand entering the weight of the associated variables with the \ntype of infertility in the bivariate analysis set at 0.2. These \nvariables were used to identify factors that were independently \nassociated with secondary infertility. Associations were \nmeasured in odds ratio (OR) with 95% confidence intervals \n(CI). Data analyses were carried out using SPSS (SPSS Inc. \nfor Windows version 10.0, Chicago). For all analyses the differences \nwere considered significant when P<0.05.\n\nA total of 619 infertile women were included in this study, \n417 (67.37%) with primary infertility and 202 (32.63%) with \nsecondary infertility.\nComparison of socio-economic and demographic characteristics between primary and secondary infertilities\nComparison of clinical characteristics between primary and secondary infertilities\nFSH; Follicle stimulating hormone, LH; Luteinizing hormone, and AMH; Anti-mullerian hormone.\nVariables independently associated with primary (n=202) and secondary (n=417) infertilities, according to the multiple logistic regression model\nOR; Odds ratio and CI; Confidence intervals.\nThe socio-economic and demographic characteristics \nbetween primary and secondary infertilities are presented \nin Table 1. The average of women’s ages were 28.7 ± \n5.7 years and 31.95 ± 5.6 years in primary and secondary \ninfertility, respectively. The average ages of their \nhusbands were 35.8 ± 7.7 years and 38.8 ± 6.8 years in \nprimary and secondary infertility, respectively. The difference \nbetween their ages was significant. Also, a good \nsocio-economic situation was reported by primary infertile \nwomen (93.3%) compared to those with secondary \ninfertility (P=0.003). After that, the majority of these \nwomen reported that their weights were normal and only \n15% had excess weight. Furthermore, a longer duration of \nmarriage was reported in secondary infertility compared \nwith primary infertility (P=0.001).\nHowever, the duration of infertility was not different in \nthe two groups of infertility. In comparison to secondary \ninfertility, primary infertile women showed enthusiasm \nfor medical diagnosis such as hysteronsalpingography \n(39.08%), and pelvic ultrasound (94.48%). However, in \nsecondary infertility, 70.3% of spouses refused to see a \nspecialist compared with the primary infertility group \n(P=0.001). The semen analysis was mainly practiced to \nevaluate primary infertility (56.8%) with a significant difference.\nThe clinical characteristics between the two groups of \ninfertility were presented in Table 2. With the exception of \nmenstrual disorders, the major causes of primary infertility \nwere entirely due to male reproductive organs, particularly \nvaricocele and abnormalities of semen, with a significant \ndifference. The main causes of secondary infertility \nwere observed mostly among women; such causes include \nhormonal disturbance, medical complications, polycystic \novary syndrome, tubal dysfunction, genital infections, \nuterine anomalies, endometriosis and adhesions without \nsignificant difference. However, according to multiple logistic \nregression models, variables independently associated \nwith primary and secondary infertility, are presented \nin Table 3. In this model, the duration of marriage (OR= \n12.263: 2.289-65.685), the age of the woman (OR=1.268: \n1.038-1.549), and the socio-economic status (OR=3.83: \n1.011-14.70) were relatively independent predictive variables \nassociated to secondary infertility.\n\nTo our knowledge, this is the first study able to determine \nthe difference between primary and secondary infertility \nin Morocco and to distinguish among the associated \nfactors. The overall rates of primary and secondary infertility \nwere 67.37 and 32.63%, respectively. This result is \nsimilar to those published in other areas of Africa ( 18 ). In \nsecondary infertility, the couple’s average age was higher \nwhen compared to those who had primary infertility. Previously, \nthis age difference has been highlighted by other \nresearchers to some degree ( 17 ).\nIn this study, this result can be explained partly by a major \nchange in the age for marriage in Morocco (from 17.3 \nyears old in 1960 to 26.6 years old in 2010) ( 19 ). The age \nof couple is clearly an important factor in reproduction, as \na woman’s fertility is strictly dependent on age. The peak \nof ability to reproduce usually around the age of 20 years \nfor women. Indeed, it starts to decline from the age of 30, \nand reduce severely from the age of 40 ( 16 ).\nIn secondary infertility, an overly long duration of marriage \nand an advanced age of the couple could decrease \ntheir chances of having a new child. This finding was \nclose to the one recorded by Keskin et al. ( 17 ). Also, the \nsocio-economic level of a couple can influence the type \nof their infertility.\nIn primary infertility, the majority of women with relatively \nhigh-to-moderate socio-economic status are able to \nresolve their infertility problems. This status can provide \nfast and easy access to several diagnostic methods and \ninfertility treatments ( 21 ). Moreover, excess body weight \nof women was a powerful determinant of infertility risk \nby ovulation disorders ( 22 ).\nAccording to the perception of the participants, however, \ntheir body weights were normal in both primary and \nsecondary infertility groups. This perception is not compatible \nwith that observed among Moroccan population \n( 23 ). Also, the apparent weight does not always reflect \nactual weight status based on the body mass index ( 24 ). \nIn fact, the diagnosis of male infertility is an essential step \nfor a quick and effective treatment. However, the sperm \nabnormality is the major cause for infertility (45.1%) \namong primary infertile men compared to secondary infertility \n(20.3%).\nThis result can be explained by the advanced age and \nalso exposure to urogenital infections affecting the quantity \nand the quality of sperms. In Africa, the sperm abnormalities \nwere estimated at 68% for the age 31-40 years \n( 15 ). In this investigation, the rate of female infertility \nwas significantly higher in secondary infertility than primary \n(66.10 vs. 44.20%). Also, the most common causes \nof female infertility were ovulation disorders, which manifest \nthemselves by sparse or absent menstrual periods \n( 22 ). Furthermore, certain studies have demonstrated that \n40 to 50% of infertilities were due to female reproductive \norgans ( 21 ).\nFinally, the difference between primary and secondary \ninfertilities in Morocco was relatively associated with \nthree independent variables, particularly the duration of \nmarriage (OR=12.263: 2.289-65.685, the woman’s age \n(OR=1.268) and socio-economic position (OR 3.83). Furthermore, \nthe bounds of this interval were very far from \nthe value 1, which means that the result was positive and \ntherefore the duration of infertility was strongly related to \nsecondary infertility.\nTo reduce the limitations in our study, further investigations \nshould be undertaken with control groups of fertile \nwomen to provide additional information on risk factors \nfor male and female infertility. Furthermore, a high-quality \ndialogue between all participants will be recommended \nfor better management of infertility.\n\nIn this study, primary and secondary infertilities were \ndue to the intersection of several demographic characteristics \nand medical factors. However, woman’s age, duration \nof marriage and socio-economic status had a significant \nimpact to accentuate the severity of secondary infertility.","source_license":"CC-BY-4.0","license_restricted":false}