{"paper_id":"79b59bf0-4a1e-44f7-b5a4-04f2842dfba5","body_text":"~ 974 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2025; 9(6): 974-977 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \nIndexing: Embase \nImpact Factor (RJIF): 6.71 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2025; 9(6): 974-977 \nReceived: 15-08-2025 \nAccepted: 21-09-2025 \n \nDr. Priyansee D Patel \nSenior Resident, Department of \nObstetrics and Gynaecology, \nGMERS Medical College, Dharpur, \nPatan, Gujarat, India  \n \nDr. Poonam Londhe \nAssociate Professor, Department of \nObstetrics and Gynaecology, \nGMERS Medical College, Dharpur, \nPatan, Gujarat, India \n \nDr. Madhusudan H Gadhvi \nAssociate Professor, Department of \nObstetrics and Gynaecology, \nGMERS Medical College, Dharpur, \nPatan, Gujarat, India \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nDr. Madhusudan H Gadhvi \nAssociate Professor, Department of \nObstetrics and Gynaecology, \nGMERS Medical College, Dharpur, \nPatan, Gujarat, India \n \nInvestigating the contributors to female infertility: A \ncomprehensive study \n \nPriyansee D Patel, Poonam Londhe and Madhusudan H Gadhvi \n \nDOI: https://www.doi.org/10.33545/gynae.2025.v9.i6d.1752  \n \nAbstract \nBackground: Female infertility is a multifactorial condition with variable etiological patterns that differ \nacross populations. Identifying specific causes is essential for accurate diagnosis and targeted management. \nMaterial and Methods:  A cross-sectional study was conducted among 120 infertile women attending a \ntertiary-care gynaecology outpatient department. Detailed clinical evaluation, hormonal profiling, \nultrasonography and diagnostic hystero-laparoscopy were performed to determine etiological factors. \nResults: Ovarian causes were most prevalent (50%), followed by tubal (22.5%), uterine (20%), peritoneal \n(18.3%) and unexplained infertility (20%). Laparoscopic evaluation enhanced diagnostic clarity, revealing \na high burden of ovarian abnorm alities, tubal blockages and peritoneal pathology including endometriosis \nand pelvic adhesions. \nConclusion: Infertility in this population demonstrated a heterogeneous etiological distribution dominated \nby ovarian, tubal and peritoneal factors. Comprehensi ve diagnostic evaluation is essential for \nindividualized management and improved reproductive outcomes. \n \nKeywords: Infertility, tubal factor, laparoscopy, ovarian dysfunction \n \nIntroduction  \nInfertility, defined as the inability to conceive after 12 months  of regular unprotected \nintercourse, remains a significant global reproductive health issue affecting millions of couples. \nRecent estimates indicate that the worldwide 12 -month prevalence of infertility is approximately \n17.5%, reflecting a substantial burd en on healthcare systems and families alike [1]. Global \nanalyses from 1990 -2021 further show a rising trend in female -specific infertility, with notable \nregional variations driven by socioeconomic, environmental, and healthcare -access differences \n[2]. \nFemale infertility arises from a diverse spectrum of etiological factors, including ovulatory \ndisorders, tubal pathology, uterine abnormalities, endometriosis, endocrine dysfunction, \ninfections, and unexplained causes. Studies have demonstrated that ovulatory dysfunctions \nparticularly polycystic ovary syndrome (PCOS)  are among the most common contributors to \nfemale infertility worldwide [3]. In addition, tubal factor infertility remains highly prevalent, \nespecially in low - and middle -income countries where pelv ic inflammatory disease (PID), \ngenital tuberculosis, and sexually transmitted infections continue to influence reproductive \nmorbidity [4]. \nUterine causes such as fibroids, intrauterine adhesions, and congenital anomalies also play a \nsignificant role in pre venting implantation or sustaining early pregnancy [5]. Endometriosis  an \ninflammatory, estrogen-dependent condition can impair fertility through altered pelvic anatomy, \nchronic inflammation, and reduced ovarian reserve, affecting approximately 10% of \nreproductive-age women and nearly 50% of infertile women in some populations [6]. \nNotably, age has emerged as one of the strongest predictors of female fertility potential. A \ntertiary-care based analysis highlighted a steep decline in ovarian reserve and oocyte  quality \nbeyond the age of 35, significantly increasing the likelihood of infertility and need for assisted \nreproductive technologies [7]. Lifestyle -related factors such as obesity, smoking, stress, \nenvironmental endocrine disruptors, and delayed childbear ing have further compounded \ninfertility rates in modern populations [8]. \nWhile global and regional data are widely available, etiological patterns often differ significantly \nacross countries and within different levels of healthcare facilities. A 2023 tert iary-care study \nfrom Asia reported ovulatory disorders as the leading cause, followed by tubal factor infertility,  \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 975 ~ \nendometriosis, and unexplained infertility, underscoring the need \nfor local data to guide clinical services [9]. Another multi -\ninstitutional study emphasized that accurate identification of \nfemale-factor infertility improves diagnostic precision, ensures \nappropriate referrals, and enhances treatment outcomes  \nespecially in resource-limited settings [10]. \nGiven the variability in etiological f actors and the influence of \nregional health dynamics, there is a need for updated, institution-\nspecific data on the incidence and distribution of various causes \nof female infertility. Therefore, the present study aims to \nevaluate the incidence  of different  causes of infertility among \nwomen attending the gynaecology outpatient department (OPD) \nof a tertiary-care centre, helping to guide targeted diagnostic and \nmanagement strategies for optimal reproductive outcomes. \n \nMaterial and Methods \nThis hospital -based observational study was conducted in the \nDepartment of Obstetrics and Gynaecology at a tertiary care \ncentre over a defined study period. A total of 120 women \npresenting to the gynaecology outpatient department (OPD) with \ncomplaints of infertility were incl uded. Infertility was defined as \nthe inability to conceive after at least 12 months of regular \nunprotected intercourse. Both primary and secondary infertility \ncases were enrolled after obtaining written informed consent. \nAll eligible participants underwent  detailed history taking, \nclinical examination, and appropriate investigations to identify \netiological factors contributing to infertility. History included \nage, duration of infertility, menstrual pattern, obstetric history, \nmedical and surgical history, p rior pelvic infections, \ncontraceptive use, lifestyle factors and previous treatment for \ninfertility. Clinical examination involved general physical \nassessment, body mass index calculation, and systemic \nexamination with emphasis on thyroid, breast and pelvi c \nevaluation. \nInvestigations were performed according to standardized \ndepartmental protocols. Ovulatory function was assessed \nthrough menstrual history, mid -luteal serum progesterone where \nnecessary, and ultrasonographic evaluation of follicular \ndevelopment. Hormonal assays including thyroid -stimulating \nhormone (TSH), prolactin and, when indicated, serum androgens \nand anti -Müllerian hormone (AMH) were obtained. Pelvic \nultrasonography was performed to identify ovarian morphology, \nuterine anomalies, endometrial thickness and adnexal pathology. \nTubal patency was evaluated through hysterosalpingography \n(HSG), and laparoscopy was advised in selected cases where \nendometriosis, adhesions or tubal pathology required further \nconfirmation. Uterine cavity abnormalities  were assessed using \ntransvaginal sonography and diagnostic hysteroscopy when \nrequired. \nBased on clinical findings and investigation results, the causes of \ninfertility were categorised into ovulatory dysfunction, tubal \nfactor, uterine factor, endometriosis, cervical factor, unexplained \ninfertility, or mixed causes. Each participant was classified \nunder the predominant etiological category. \nAll collected data were systematically recorded in a predesigned \nproforma and subsequently entered into a spreadsheet f or \nanalysis. Statistical analysis was performed using appropriate \nsoftware. Descriptive statistics including frequency distribution \nand percentages were computed to determine the incidence of \ndifferent causes of infertility within the study population. \nResults were presented in tables and charts wherever applicable. \nEthical approval was obtained from the institutional ethics \ncommittee prior to the commencement of the study. \n \nResults \nA total of 120 women with infertility were included in the \npresent study. O f these, 74 women (61.6%) presented with \nprimary infertility and 46 women (38.4%) with secondary \ninfertility. The distribution of etiological factors showed \nconsiderable overlap between the two groups, although certain \npatterns emerged on detailed evaluati on. As shown in Table 1, \novarian factor infertility constituted the largest category overall, \naffecting half of the study population. Among women with \nprimary infertility, 54.05% exhibited ovarian dysfunction, \nwhereas 43.47% of secondary infertility cases were attributed to \novarian causes. Tubal factor infertility accounted for 22.5% of \nall cases, with a relatively similar distribution between primary \nand secondary infertility. Uterine factor infertility contributed to \n20% of cases, whereas peritoneal facto rs such as endometriosis, \nadhesions and pelvic pathology were responsible for 18%. \nUnexplained infertility continued to represent a significant \nproportion and was more common among secondary infertility \npatients at 28.26%, compared to 14.86% in primary infertility. \nLaparoscopic evaluation was performed in 94 women (78.3%), \nproviding detailed information on intra -abdominal and pelvic \npathology. The findings are presented in Table 2. Ovarian \nabnormalities were the most frequently detected pathology, \nidentified in 40.42% of women who underwent laparoscopy. \nPolycystic ovarian morphology constituted the majority of \novarian findings and was more frequently observed among those \nwith primary infertility. Tubal blockage was noted in 22.34% of \ncases, including bilater al block, unilateral block and \nhydrosalpinx. Peritoneal causes such as endometriosis, pelvic \nadhesions and genital tuberculosis contributed significantly to \nprimary infertility, accounting for 25.53% of laparoscopic \nfindings. Uterine pathology including fi broids, müllerian \nanomalies and hypoplastic uterus represented 11.7% of \nabnormalities. \nHystero-laparoscopic correlation of etiological factors is \nsummarized in Table 3. Ovarian factors remained the \npredominant cause (38.29%), followed by tubal factors (27.65%) \nand peritoneal factors (24.46%). Uterine  causes contributed to \n25.53% of cases, while unexplained infertility accounted for \n22.34% of the evaluated women. This combined evaluation \nstrengthened the diagnostic precision and highlighted the \nmultifactorial nature of infertility among the study participants. \n \nTable 1: Causes of infertility (N = 120) \n \nCauses of infertility Primary (N=74) Number Primary % Secondary (N=46) Number Secondary % Total (N=120) Number Total % \nOvarian factor 40 54.05 20 43.47 60 50.00 \nTubal factor 17 22.97 10 21.73 27 22.50 \nUterine factor 15 20.27 9 19.56 24 20.00 \nPeritoneal factor 15 20.27 7 15.21 22 18.33 \nUnexplained 11 14.86 13 28.26 24 20.00 \n \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 976 ~ \nTable 2: Laparoscopically identified pathology of infertility (N = 94) \n \nCauses of infertility Primary (N=58) Frequency (%) Secondary (N=36) Frequency (%) Total (N=94) Frequency (%) \nOvarian factor \nPCOS 14 (24.13) 7 (19.44) 21 (22.34) \nSimple cyst 1 (1.72) 1 (2.78) 2 (2.12) \nChocolate cyst 5 (8.62) 1 (2.78) 6 (6.38) \nComplex cyst 5 (8.62) 1 (2.78) 6 (6.38) \nStreak ovaries 1 (1.72) 0 1 (1.06) \nTotal ovarian 26 (44.82) 10 (27.78) 38 (40.42) \nTubal factor \nBilateral block 9 (15.51) 3 (8.33) 12 (12.76) \nUnilateral block 3 (5.17) 6 (16.67) 9 (9.57) \nHydrosalpinx 0 2 (5.56) 2 (2.12) \nTotal tubal 12 (20.68) 11 (30.56) 23 (24.46) \nUterine factor \nFibroid 3 (5.17) 2 (5.56) 5 (5.31) \nMullerian anomaly 2 (3.44) 1 (2.78) 3 (3.19) \nHypoplastic uterus 1 (1.72) 0 1 (1.06) \nTotal uterine 6 (10.34) 3 (8.33) 9 (9.57) \nPeritoneal factor  \nEndometriosis 5 (8.62) 4 (11.11) 9 (9.57) \nPelvic adhesions 4 (6.89) 2 (5.56) 6 (6.38) \nTuberculosis 5 (8.62) 0 5 (5.31) \nTotal peritoneal 14 (24.13) 6 (16.67) 20 (21.27) \n \nTable 3: Hystero-laparoscopically identified causative factors of infertility (N = 94) \n \nCauses of infertility Primary (N=58) Number Primary % Secondary (N=36) Number Secondary % Total (N=94) Number Total % \nUterine factor 15 25.86 8 22.22 23 24.46 \nTubal factor 15 25.86 11 30.56 26 27.65 \nOvarian factor 26 44.82 10 27.78 36 38.29 \nPeritoneal factor 14 24.13 6 16.67 20 21.27 \nUnexplained 11 18.96 10 27.78 21 22.34 \n \nDiscussion: The present study examined the distribution of \netiological factors contributing to infertility among women \nattending a tertiary-care gynaecology outpatient department. The \nfindings reaffirm the multifactorial nature of infertility, with \novarian, tubal, uterine and peritoneal pathologies contributing \nsubstantially to both primary and secondary infertility. Ovarian \ndysfunction emerged as the leading cause, consistent with global \nevidence showing that ovulatory disorders  particularly PCOS  \nremain the most frequent contributor to female infertility in \nreproductive-age women [11]. In recent literature, ovulatory \ndysfunction has been closely associated with metabolic \ndisturbances, chroni c anovulation and endocrine dysregulation, \nwhich collectively impair fecundity and contribute to the rising \nburden of infertility in younger age groups [12]. \nTubal factor infertility accounted for more than one -fourth of \ncases on combined hystero-laparoscopic evaluation. This finding \naligns with contemporary studies demonstrating that tubal \npathology continues to be a major cause of infertility, especially \nin populations with high prevalence of pelvic inflammatory \ndisease, post -infectious sequelae and delay  in seeking \ngynecological care [13]. Laparoscopic assessment remains the \ngold standard for accurate identification of tubal blockages, \nhydrosalpinx and peritubal adhesions, as imaging alone \nfrequently underestimates the extent of tubal damage. \nPeritoneal causes including endometriosis, pelvic adhesions and \ngenital tuberculosis  were also significant contributors. \nEndometriosis, identified in nearly 10% of women, is known to \nreduce fecundity through a combination of pelvic inflammation, \naltered immunologic en vironment and mechanical distortion of \npelvic structures. Recent evidence emphasizes that even \nminimal-to-mild endometriosis significantly affects reproductive \npotential and requires targeted management to improve \nconception rates [14]. Genital tuberculosi s, although less frequent \nglobally, remains a notable contributor in South Asian \npopulations, and its diagnosis is frequently delayed due to subtle \nor absent clinical symptoms. \nUterine factors such as fibroids, congenital malformations and \nhypoplastic uter us accounted for over 20% of cases in the \npresent study. According to recent literature, uterine anomalies \ndemonstrate varying degrees of impact on fertility depending on \nthe location, size and distortion of the endometrial cavity [15]. \nFibroids impinging upon the cavity, in particular, are associated \nwith implantation failure and increased miscarriage risk. \nUnexplained infertility constituted a considerable proportion of \ncases, especially among secondary infertility patients. This \ncategory reflects the lim itations of current diagnostic modalities \nand the complex interplay of endometrial receptivity, \nimmunological factors and subtle ovulatory defects. As \nemphasized in recent reviews, unexplained infertility \nunderscores the need for advanced diagnostic tools and \nindividualized treatment approaches [12]. \nOverall, the findings of this study resonate with recent global \ntrends indicating that infertility remains a heterogeneous \ncondition requiring comprehensive evaluation. The integration \nof clinical assessment, h ormonal profiling, transvaginal \nultrasonography and diagnostic laparoscopy improves diagnostic \naccuracy and allows for targeted management. The high \nproportion of ovarian and tubal pathology in this population \nhighlights the importance of early detection, lifestyle \nmodification, infection prevention strategies and timely referral \nto specialized infertility services. \n \nConclusion: Female infertility in this tertiary -care population \nwas predominantly attributed to ovarian, tubal and peritoneal \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 977 ~ \nfactors, with a noticeable contribution from uterine \nabnormalities and unexplained causes. Laparoscopic evaluation \nsignificantly enhanced diagnostic precision, identifying multiple \ncoexisting pathologies not detectable through routine imaging. \nThese findings highlight the  complex and multifactorial nature \nof infertility and emphasize the need for early, comprehensive, \nand individualized evaluation. Strengthening diagnostic facilities \nand awareness among reproductive -age women may improve \nfertility outcomes and reduce long-term reproductive morbidity. \n Conflict of interest: No! Conflict of interest is found \nelsewhere considering this work. \n Source of Funding: T here was no financial support \nconcerning this work \n \nReferences \n1. Cox CM, Thoma ME, Tchangalova N, Mburu G, Bornstein \nMJ, Johnson CL. Infertility prevalence and the methods of \nestimation from 1990 to 2021: a systematic review and \nmeta-analysis. Human Reproduction Open.  \n2022;2022(4):hoac051. \n2. Liu J, Smith A, Zhao M, Nguyen L, Das R, Lee S. Global, \nregional, and national burd en trends of female infertility, \n1990-2021: a population -based analysis. Scientific Reports. \n2023;13:14582. \n3. Dinsdale NL, Heidari M, Vasilev YA, Stuparich MA, \nShemanko CS, Shaw JLA. Endometriosis and polycystic \novary syndrome are diametric disorders. Fronti ers in \nEndocrinology. 2021;12:660400. \n4. 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International Journal of \nClinical Obstetrics and Gynaecology 2025;9(6):974-977.  \n \n \nCreative Commons (CC) License \nThis is an open access journal, and articles are distributed under the terms \nof the Creative Commons Attribution -Non Commercial-Share Alike 4.0 \nInternational (CC BY -NC-SA 4.0) License, which allows others to remix, \ntweak, and build upon the wo rk non-commercially, as long as appropriate \ncredit is given and the new creations are licensed under the identical terms.","source_license":"CC0","license_restricted":false}