{"paper_id":"3dcef86a-c8c2-4950-8666-3686e037ac93","body_text":"The global total fertility rate (TFR) has declined by more than half, from 4.84 to 2.23, between 1950 and 2021 [ 1 ]. Infertility is a major factor affecting fertility and human health, and has become a worldwide public health issues, affecting 17.5% adults globally (1/6 of global population) [ 2 ,  3 ,  4 ]. Infertility is particularly devastating for women. The prevalence of infertility affects approximately 8%–12% of couples of reproductive ages. Although female factors account for approximately 50% of infertility cases, they are primarily responsible for 70%–80% of cases [ 5 ]. Moreover, it also elevates the risk of endometrial and ovarian cancers, and engenders other social and psychological issues [ 6 ,  7 ,  8 ]. Addressing infertility is central to achieving Sustainable Development Goal (SDG) 3 and 5 by the World Health Organization (WHO) [ 9 ]. And a substantial proportion of infertility cases are preventable through the effective management of underlying reproductive disorders, such as endometriosis and PCOS [ 10 ]. Therefore, identifying the burden of infertility‐related diseases and their attribution to infertility burden among WCBA is crucial for reducing the infertility incidence.\nThe major diseases associated with infertility in female include ovulatory dysfunction (e.g., PCOS), tubal disease, endometriosis, uterine/cervical factors and unexplained factors [ 11 ]. Among these, PCOS and endometriosis are the leading causes of infertility [ 12 ], and unexplained infertility is also a major cause of infertility among WCBA [ 13 ]. Endometriosis, PCOS, and unexplained infertility typically require long‐term management strategies [ 14 ,  15 ] and substantial healthcare expenditures [ 16 ,  17 ]. However, early detection and intervention for three conditions can reduce the infertility incidence. These diseases are strongly influenced by economic development, availability of medical resources, and access to healthcare services [ 18 ]. Therefore, it is crucial to systematically assess trend in the burden of these diseases from 1990 to 2021 to inform effective prevention and treatment strategies.\nAlthough the global burden of endometriosis, PCOS, and unexplained infertility has been respectively assessed in several researches [ 19 ,  20 ,  21 ], these studies primarily focused on the burden of diseases themselves, ignoring the relationship among three diseases and the relationship between three diseases and infertility. Moreover, the burden of infertility attributable to three diseases in different regions is unclear. Therefore, we comprehensively estimated the burden of three diseases and infertility attributable to them in various regions, and compared the disparities in the burden of three diseases among WBCA using the GBD 2021 to provide evidence‐based support for the implementation of the strategies to mitigate infertility‐related diseases and infertility, with the aim of promoting the development of female reproductive health.\n\nGlobal Burden of Diseases Study (GBD) 2021 was produced and led by the Institute for the Health Metrics and Evaluation (IHME), and aimed to provide the comprehensive estimates of global disease burden using 100983 data sources, including census, surveys, disease registries, and other sources ( https://www.healthdata.org/data‐tools‐practices/data‐sources ). GBD 2021 reported the epidemiological indexes including incidence, prevalence, disability‐adjusted life‐years (DALYs), years of life lost (YLLs) and years lived with disability (YLDs) due to 371 diseases and injuries by sex, 25 age groups with 5 years as an interval, 204 countries and territories grouped into 7 super‐regions and 21 regions from 1990 to 2021 ( https://vizhub.healthdata.org/gbd‐results/ ) [ 22 ]. We extracted data on prevalence, DALYs of three diseases and prevalence, YLDs of infertility attributable to them from the GBD 2021 among WCBA at five‐year intervals from 1990 to 2021. All estimates for this study are stratified by female, age from 15 to 49 years, 21 regions, and 204 countries and territories, covering the period from 1990 to 2021.\nIn GBD 2021, endometriosis is defined as growth of endometrial tissue outside the uterus, diagnosed via pelvic examination with laparoscopy or laparotomy confirmation according to ACOG guidelines. PCOS is characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovaries according to National Institutes of Health (NIH). Unexplained infertility refers to infertility excluding known causes such as pelvic inflammatory disease, PCOS, and endometriosis among WCBA [ 22 ]. The international classification of disease codes was defined in the supplementary appendix (Table  S1 ). In addition, infertility is defined as failure to conceive and have a livebirth via regular unprotected sexual intercourse, encompassing primary infertility and secondary infertility. Infertility is an impairment caused by eight identified causes (e.g., chlamydia, gonorrhea, other STIs, endometriosis, PCOS, maternal sepsis, congenital Turner syndrome, congenital urogenital anomalies) and unknown causes in women according to GBD 2021 [ 23 ]. Primary infertility was defined the female has never been pregnant in a couple, while secondary infertility was defined the female who has been pregnant before and successfully delivered is unable to become pregnant again [ 24 ]. All rates were expressed per 100,000 persons. Women of childbearing age was defined as 15 to 49 years by WHO, denotes the period of females with the reproductive ability and cyclical sex hormones changes [ 25 ]. The socio‐demographic index (SDI) is a composite measure of total fertility rate (females age <25 years), income per capita, and average years of educational attainment (individuals age ≥15 years) [ 26 ].\nThe prevalence and YLDs of infertility attributable to endometriosis, PCOS, and unexplained infertility among WCBA from 1990 to 2021 were retrieved directly from the GBD 2021. For endometriosis and PCOS, the prevalence of infertility attributable to them was determined by their own prevalence multiply the risk attribution. The attributable fractions of endometriosis and PCOS were derived from the Australian Longitudinal Women's Health Study (ALWHS) ( http://www.alswh.org.au/ ). For unexplained infertility, the attribution to infertility was calculated by subtracting the summed attribution to infertility prevalence of eight known causes (including endometriosis, PCOS, STIs) from overall prevalence of infertility according to GBD 2021 ( https://vizhub.healthdata.org/gbd‐results/ ) [ 22 ]. The infertility attributable to three diseases did not lead to mortality, therefore the DALYs were equal to YLDs, so we only estimated the YLDs. The primary infertility and secondary infertility attributable to them were also estimated from the GBD disability weights survey. Additionally, we estimated the percentage contribution of these 3 diseases as risk factors in 2021.\nWe calculated the age‐standardized rates (ASRs) and their average annual percent changes (AAPCs) to assess the global, regional and national trends of three diseases on prevalence and DALYs in women of childbearing age 15–49 years. We also estimated the ASRs of prevalence and YLDs of infertility attributable to three diseases, respectively. ASRs were standardized by the global age‐standard population, and rates are shown as per 100,000 persons. The 95% uncertainty interval (UI) was used to estimate the heterogeneity of ASR [ 13 ]. The AAPC was estimated to assess the temporal trends in age‐standardized prevalence and DALYs rates for three diseases. If both the AAPC and its 95% CI were above or below zero, it indicated the trend of ASR was increase or decline, respectively [ 26 ].\nWe used the smoothing spline models to evaluate the relationships between the burden of endometriosis, PCOS, and unexplained infertility among WCBA and SDI for 21 regions, 204 countries and territories. Additionally, we used Spearman correlation analysis to calculate  r  indices and  p  values for these relationships. Two‐tailed  p  < 0·05 was considered statistically significant. All statistical analyses and mapping were conducted using R software (version 4·4·1).\n\nIn 2021, the global age‐standardized prevalence rates (ASPRs) of endometriosis, PCOS, and unexplained infertility were 1070.7, 3364.5, and 5586.2 per 100,000 population, respectively (Table  1 ; Figure  1A ). Between 1990 and 2021, the global ASPR of endometriosis significantly decreased by –1.02. In contrast, PCOS and unexplained infertility significantly increased by annual average of 0.74 and 0.70, respectively (Table  1 ; Figure  1C ). The global age‐standardized DALYs rates (ASDRs) of DALYs for endometriosis, PCOS, and unexplained infertility were 98.69, 29.51, and 30.55, respectively (Table  1 ; Figure  1B ). Trends in ASDRs for these diseases followed patterns similar to their respective ASPRs (Table  1 ; Figure  1D ).\nPrevalence and DALYs of endometriosis, PCOS, and unexplained infertility for WCBA in 1990 and 2021, and their AAPC from 1990 to 2021 in global and 21 regions.\nDALYs: disability‐adjusted life‐years; PCOS: polycystic ovarian syndrome; WCBA: women of childbearing age; AAPC: average annual percentage change.\nAge‐standardized prevalence and DALYs rates of endometriosis, PCOS, and unexplained infertility for WCBA in 2021, and their AAPC from 1990 to 2021 in global and 21 GBD regions. Age‐standardized rates of prevalence (A) and DALYs (B), and average annual percentage change of age‐standardized rate of prevalence (C) and DALYs (D). PCOS, polycystic ovarian syndrome; AAPC, average annual percentage change; ASR, age‐standardized rate; DALYs, disability‐adjusted life‐years; GBD, Global Burden of Diseases, Injuries, and Risk Factors Study; PCOS, polycystic ovarian syndrome; WCBA, women of childbearing age.\nIn 2021, the highest ASPRs of endometriosis were observed in Oceania, Eastern Europe, and Western Sub‐Saharan Africa, while the lowest rate was recorded in high‐income North America (Table  1 ; Figure  1A ). Eastern Europe was only region to experience an increase in the ASPR, with an AAPC of 0.33 from 1990 to 2021 (Table  1 ; Figure  1C ). Nationally, Niger had the highest ASPR of endometriosis. Notably, nine countries reported an increase in ASPRs, with Iceland showing the largest rise (AAPC: 1.24) (Table  S2  online).\nFor PCOS, the highest ASPRs were observed in high‐income Asia Pacific, Australasia, and Western Europe, while the lowest rates were recorded in Central Europe and Eastern Europe (Table  1 ; Figure  1A ). From 1990 to 2021, Tropical Latin America was only region to experience a decrease in the ASPR, with an AAPC of –0.17 (Table  1 ; Figure  1C ). Nationally, the highest ASPRs were observed in Italy, and United States of America with an AAPC of –0.58 showed the largest decrease (Table  S3  online).\nRegarding unexplained infertility, the highest ASPRs in 2021 were recorded in East Asia and Eastern Europe, while the lowest rates were found in Australasia and Andean Latin America (Table  1 ; Figure  1A ). From 1990 to 2021, Andean Latin America had the largest increase, with an AAPC of 8.22% (Table  1 , Figure  1C ). At the national level, the highest ASPR was observed in Central African Republic (Table  S4  online). Notably, the trends of ASDRs for three diseases also showed consistent features with each own ASPRs (Tables  1  and  S2–S4  online).\nIn 2021, the global prevalence and DALYs rates for endometriosis showed a significant increase among individuals aged 15–29 years. The DALYs rate for endometriosis was higher than those for PCOS and unexplained infertility. For PCOS, the global burden rates remained relatively stable across the 15–49 years. In contrast, the global burden for unexplained infertility exhibited a marked increase with age, peaking at 35–39 years and subsequently declining in the 40–49 age group (Figure  2A, B ). From 1990 to 2021, the AAPC in burden for endometriosis demonstrated a declining trend across all age groups contrasting with PCOS. For unexplained infertility, the trends in prevalence and DALYs showed an increase among individuals aged 20–44 years, with the largest rise occurring in the 20–29 age group. (Figure  2C, D ).\nThe global prevalence and DALYs of endometriosis, PCOS, and unexplained infertility for WCBA at 7 age groups in 2021, and their AAPC from 1990 to 2021. Numbers and rates of prevalence (A) and DALYs (B) and AAPC of prevalence rate (C) and DALYs rate (D) of endometriosis, PCOS, and unexplained infertility. AAPC, average annual percentage change; ASR, age‐standardized rate; GBD, Global Burden of Diseases, Injuries, and Risk Factors Study; PCOS, polycystic ovarian syndrome; WCBA, women of childbearing age.\nThe ASPR of endometriosis was negatively correlated with the SDI at both regional ( r  = –0.61) and national levels (Figures  3A  and  S1A  online). Niger had the highest higher‐than‐expected rates of endometriosis in 2021 (Figure  S1A  online). However, the ASPR of PCOS significantly increased with SDI ( r  = 0.41) among 21 regions (Figure  3B ). Nationally, Italy, Japan and New Zealand had significantly higher‐than‐expected rates of PCOS in 2021 (Figure  S2A  online). The ASPR of unexplained infertility was negatively correlated ( r  = –0.29) (Figure  3C ). The Central African Republic displayed significantly higher‐than‐expected rates in 2021 (Figure  S3A  online). Moreover, the relationship between ASDR of three diseases and SDI was consistent with their respective observed correlation (Figures  3  and  S1–S3  online).\nAge‐standardized prevalence and DALYs rates of endometriosis, PCOS, and unexplained infertility, globally and for 21 GBD regions, by SDI, 1990–2021. Age‐standardized prevalence rates of endometriosis (A), PCOS (B), unexplained infertility (C) by SDI. Age‐standardized DALYs rates of endometriosis (D), PCOS (E), unexplained infertility (F) by SDI. Expected values with 95% CI based on SDI and disease rates in 21 regions are shown as a solid line and shaded area. 32 points are plotted for each region and show the observed age‐standardized rate for each year from 1990 to 2021. Points above the solid line represent a higher‐than‐expected burden, while those below the line show a lower‐than‐expected burden. PCOS, polycystic ovarian syndrome; DALYs, disability‐adjusted life‐years; GBD, Global Burden of Diseases, Injuries, and Risk Factors Study; SDI, socio‐demographic index.\nIn 2021, the global ASPRs of infertility attributable to endometriosis, PCOS, and unexplained infertility were 60.6, 638.2, and 5586.2, respectively (Table  S5  online; Figure  4A ). Meanwhile, the corresponding global age‐standardized YLDs rates for infertility due to three diseases were 0.4, 3.7, and 31.2, respectively(Table  S5  online; Figure  S4A ). Furthermore, the global burden of primary and secondary infertility attributable to three diseases exhibited patterns consistent with overall infertility trends (Tables  S5–S7  online; Figures  4  and  S4  online).\nAge‐standardized prevalence rates and proportions of prevalence cases for infertility, primary infertility and secondary infertility attributable to endometriosis, PCOS, and unexplained infertility for WCBA globally and regionally in 2021. Age‐standardized prevalence rate of infertility (A), primary infertility (B), and secondary infertility (C). Proportions of prevalence cases of infertility (D), primary infertility (E), and secondary infertility (F). PCOS, polycystic ovarian syndrome; WCBA, women of childbearing age; YLDs, years lived with disability.\nRegionally, infertility attributable to endometriosis showed the lowest burden (prevalence and YLDs) among three conditions. Oceania had the highest regional burden for both infertility and secondary infertility, while Eastern Europe showed the highest burden for primary infertility attributable to endometriosis. Concurrently, high‐income Asia Pacific carried the highest burden for both infertility and primary infertility attributable to PCOS, with Australasia accounting for 75.37% of PCOS‐attributable cases. Additionally, infertility attributable to unexplained infertility had the highest burden in East Asia and South Asia. Furthermore, the proportion of the burden of secondary infertility attributable to endometriosis, PCOS, and unexplained infertility was higher than that for primary infertility globally and in most regions in 2021 (Tables  S5–S7  online; Figures  4  and  S5  online).\n\nThis study provides a comprehensive analysis of the geographical and temporal trends in the burden of endometriosis, PCOS, unexplained infertility, and their contribution to infertility among WCBA. The main findings are summarized as follows: (1) There are significant disparities in burden of these diseases, as well as regional disparities. From 1990 to 2021, the burden of unexplained infertility and PCOS increased. Although the burden of endometriosis decreased during this period, there were significant regional disparities. (2) The global burden of endometriosis and unexplained infertility characterized by an initial increase followed by a decline with age. In contrast, the global age‐specific prevalence and DALYs rates of PCOS maintained relatively stable across various age groups. (3) The ASPR and ASDR for endometriosis and unexplained infertility decreased with SDI, whereas the burden of PCOS increased with SDI. (4) Infertility attributable to PCOS exhibited higher age‐standardized prevalence and YLDs rates compared to endometriosis in most regions.\nOur study identified a significant decline in global ASPR and ASDR of endometriosis from 1990 to 2021. Although the trend aligns with a systematic review revealing a decrease in prevalence over the past 30 years using health/insurance data [ 27 ], it should be interpreted with caution. Previous evidence has demonstrated that the true prevalence of endometriosis is likely underestimated due to diagnostic delays and barriers [ 28 ,  29 ]. The observed decline may partly be influenced by persistent barriers to healthcare access and diagnostic inertia, particularly in low‐resource settings. This hypothesis is supported by a report from a large US health system's electronic medical records database, which documented a decline in endometriosis incidence from 30.2 to 17.4 per 100,000 between 2006 and 2015, while concurrent diagnoses of chronic pelvic pain increased from 3.0% to 5.6% [ 30 ]. This highlights the need for considering this potentially affected population when estimating the burden and implementing health strategies. Regionally, high‐SDI regions (e.g., high‐income North America) recorded lower prevalence than low‐ and middle‐SDI region (e.g., Oceania and Sub‐Saharan Africa), aligning with prior findings [ 31 ]. This disparity likely stems from a complex combination of factors, including disparities in universal health coverage, cultural and socioeconomic differences, as well as environmental issues [ 32 ]. Additionally, our study demonstrated that the global prevalence of endometriosis was highest at 25–29 years among WCBA, contrasting with previous reports of 35–49 years [ 33 ,  34 ]. This shift could result from increased awareness of endometriosis management in adolescents [ 35 ,  36 ].\nFor PCOS, our findings revealed a global increase in ASPR and ASDR from 1990 to 2021, with high‐income Asia Pacific showing the highest burden in 2021. This aligns with previous studies [ 37 ,  38 ], highlighting the need for improved prevention and management among WCBA. This increase may be partly attributable to the rising prevalence of obesity [ 39 ], as evidence shows a positive correlation between PCOS and obesity [ 40 ]. Regionally, Tropical Latin America exhibited a declining trend in prevalence and DALYs, contrasting with another study [ 20 ]. This discrepancy could result from Brazil's expanded Family Health Strategy (FHS) since the 1990s, which reduced inequalities in primary healthcare services [ 41 ,  42 ,  43 ]. High‐income regions exhibited the higher ASPR of PCOS, consistent with previous study [ 44 ], reflecting disparities across regions, particularly higher prevalence in Europe and North America compared to Asia. These disparities may reflect regional differences in diagnostic intensity, healthcare‐seeking behavior, and environmental or lifestyle [ 45 ,  46 ].\nRegarding unexplained infertility, global ASPR and ASDR increased from 1990 to 2021, consistent with previous reports [ 47 ,  48 ]. This trend may stem from environmental and lifestyle changes [ 49 ] and delayed childbearing age [ 50 ]. Female age is a critical factor, with fertility declining due to irreversible changes in ovarian reserve [ 51 ]. We found that Sub‐Saharan Africa showed a significant decline in the prevalence of unexplained infertility and higher prevalence compared other regions in 2021. Similarly, a previous study regarding the global perspective on infertility in the 21st century summarized that, despite infertility rates appeared to decline, Sub‐Saharan Africa still remained high rates of infertility and fertility [ 10 ]. The high prevalence may be explained by the unique social and political context as well as limited resource [ 52 ], while the decline may relate to reduced unsafe abortions and limited contraception access in Sub‐Saharan Africa [ 53 ,  54 ]. Australasia and high‐income North America recorded lower ASPR of unexplained infertility compared to low‐income regions. This may be attributed to investments in infertility services and affordable assisted reproductive technologies (e.g., IVF) [ 55 ,  56 ], which highly relying on the socioeconomic development.\nFor infertility attributable to endometriosis, PCOS, and unexplained infertility, our study demonstrated that unexplained infertility contributed the highest burden of infertility among most regions, partly due to unknown causes such as genetics, behavior, and socioeconomic factors excluding nine identified factors in GBD 2021 [ 22 ,  57 ]. Endometriosis contributed the lowest burden of infertility likely due to the effective treatments like surgery and assisted reproductive technologies (ART) in treating endometriosis‐associated infertility [ 58 ,  59 ]. High‐income Asia Pacific and Australasia exhibited higher burdens of infertility attributable to PCOS than unexplained infertility, linked to high PCOS incidence in these regions [ 27 ], indicating an urgent need for prevention and improvement in the treatment of PCOS and PCOS‐related infertility. In addition, our analysis revealed that three diseases contributed more to secondary infertility than primary infertility. Similarly, previous studies have reported that these diseases mainly lead to the structural or anatomic alterations, ovulatory dysfunction, and disruption of the fertilization microenvironment in WCBA [ 60 ,  61 ,  62 ]. These results highlight the dual burden of gynecological disorders, requiring targeted interventions for disease management and fertility preservation.\nOur study revealed that persistent disparities in healthcare infrastructure and socioeconomic development worldwide are critical drivers of burden of these diseases. Comprehensive strategies integrating multi‐sectoral approaches are urgently needed. In low‐ and middle‐income countries (LMICs), investment should prioritize strengthening primary‐care diagnostic capacity [ 63 ,  64 ] (e.g., ultrasound and basic hormone testing), expanding reproductive health service [ 65 ], and improving insurance coverage to enhance early detection and treatment [ 66 ]. In high‐income countries (HICs), public health strategies that integrate lifestyle interventions [ 67 ] and standardize PCOS management [ 68 ]. Additionally, affordability and accessibility of ART should be improved through subsidies, technology transfer, and public–private collaboration [ 69 ]. National health systems should expand coverage for early detection of reproductive diseases and infertility prevention, with particular attention to underserved populations.\nMeanwhile, Clinical practice must adapt to address persistent diagnostic and management gaps. In low‐resource environments, simplified diagnostic criteria and awareness of nonspecific symptoms (e.g., chronic pelvic pain) can reduce underdiagnosis of conditions like endometriosis [ 70 ], especially among younger women [ 71 ]. PCOS management should extend beyond fertility concerns to include long‐term monitoring and mitigation of metabolic and cardiovascular risks, supported by comprehensive lifestyle interventions encompassing diet, exercise, and weight modifications [ 72 ]. Finally, implementing evidence‐based, standardized care pathways will help ensure consistent, high‐quality treatment across diverse healthcare environments.\nHowever, our study has several limitations. First, the accuracy of burden estimates depends on the quality and completeness of primary data, with sparse data in LMICs likely leading to underestimation. Second, heterogeneity in diagnostic criteria, particularly the evolving definitions of PCOS, limits comparability across regions. Third, cultural factors can influence healthcare‐seeking behavior, thereby affecting diagnosis rates. Fourth, significant difference in healthcare systems and population characteristics across countries, require cautious interpretation of the results differences. Fifth, our analysis focused solely on prevalence and DALYs of these diseases, as GBD 2021 only provided these critical indicators for unexplained infertility. Sixth, the lack of specific phenotype data limited our ability to explore the burden of clinical subtypes. Finally, detection bias may overestimate the burdens in high‐income regions with advanced healthcare systems and higher healthcare seeking behaviors, so lower‐reported regions should not be overlooked in resource allocation.\n\nIn summary, the global burden of endometriosis, unexplained infertility and PCOS have resulted in significant public health challenges and influence on infertility. The burden of infertility attributable to these conditions exhibited notable regional differences between high‐ and low‐income settings. Addressing these disparities requires policies tailored to demographic, regional, and disease‐specific factors. In LMICs, strategies should prioritize strengthening diagnostic capacity for these diseases, expanding access to ART, and integrating screening into routine gynecological care. In HICs, efforts should emphasize weight management strategies to prevent PCOS. The implementation of these targeted measures can help alleviate the global burden of these conditions and improve reproductive health outcomes.\n\nThe authors declare no conflicts of interest.\n\nFigure S1 : Age‐standardized prevalence and DALYs rates of endometriosis for 204 countries and territories in 2021, by SDI. Age‐standardized rates of prevalence (A) and DALYs (B) by SDI. Expected values are shown as a solid line. 204 points are plotted for each country and territory. Points above the solid line represent a higher‐than‐expected burden, while those below the line show a lower‐than‐expected burden. SDI: socio‐demographic index.\nFigure S2 : Age‐standardized prevalence and DALYs rates of PCOS for 204 countries and territories in 2021, by SDI. Age‐standardized rates of prevalence (A) and DALYs (B) by SDI. Expected values are shown as a solid line. 204 points are plotted for each country and territory. Points above the solid line represent a higher‐than‐expected burden, while those below the line show a lower‐than‐expected burden. PCOS: polycystic ovarian syndrome; SDI: socio‐demographic index.\nFigure S3 : Age‐standardized prevalence and DALYs rates of unexplained infertility for 204 countries and territories in 2021, by SDI. Age‐standardized rates of prevalence (A) and DALYs (B) by SDI. Expected values are shown as a solid line. 204 points are plotted for each country and territory. Points above the solid line represent a higher‐than‐expected burden, while those below the line show a lower‐than‐expected burden. SDI, socio‐demographic index.\nFigure S4 : Age‐standardized YLDs rates and proportions of YLDs cases for infertility, primary infertility and secondary infertility attributable to endometriosis, PCOS, and unexplained infertility for WCBA in 2021. Age‐standardized YLDs rates of infertility (A), primary infertility (B), and secondary infertility (C). Proportions of YLDs cases of infertility (D), primary infertility (E), and secondary infertility (F). PCOS: polycystic ovarian syndrome; WCBA: women of childbearing age; YLDs: years lived with disability.\nFigure S5 : Proportion of prevalence and YLDs for primary infertility and secondary infertility attributable to endometriosis, PCOS, and unexplained infertility by global and 21 GBD regions in 2021. The proportion of age‐standardized prevalence rate for primary infertility and secondary infertility attributable to endometriosis(A), unexplained infertility (B), and polycystic ovarian syndrome (C). The proportion of age‐standardized YLDs rate for primary infertility and secondary infertility attributable to endometriosis (D), unexplained infertility (E), and polycystic ovarian syndrome (F). PCOS: polycystic ovarian syndrome; WCBA: women of childbearing age; YLDs: years lived with disability.\nTable S1 : International Classification of Diseases (ICD) codes mapped to endometriosis and PCOS in GBD 2021.\nTable S2 : Prevalence and DALYs cases and age‐standardized rate of endometriosis for WCBA in 1990 and 2021, and their average annual percentage change from 1990 to 2021 by countries and territories.\nTable S3 : Prevalence and DALYs cases and age‐standardized rate of polycystic ovarian syndrome for WCBA in 1990 and 2021, and their average annual percentage change from 1990 to 2021 by countries and territories.\nTable S4 : Prevalence and DALYs cases and age‐standardized rate of unexplained infertility for WCBA in 1990 and 2021, and their average annual percentage change from 1990 to 2021 by countries and territories.\nTable S5 : Prevalence and YLDs cases and age‐standardized rate of infertility attributable to endometriosis, PCOS, and unexplained infertility for WCBA in 2021 by location.\nTable S6 : Prevalence and YLDs cases and age‐standardized rate of primary infertility attributable to endometriosis, PCOS, and unexplained infertility for WCBA in 2021 by location.\nTable S7 : Prevalence and YLDs cases and age‐standardized rate of secondary infertility attributable to endometriosis, PCOS, and unexplained infertility for WCBA in 2021 by location.","source_license":"CC-BY-4.0","license_restricted":false}