Investigating the contributors to female infertility: A comprehensive study

Background: Female infertility is a multifactorial condition with variable etiological patterns that differ across populations. Identifying specific causes is essential for accurate diagnosis and targeted management.

A cross-sectional study was conducted among 120 infertile women attending a tertiary-care gynaecology outpatient department. Detailed clinical evaluation, hormonal profiling, ultrasonography and diagnostic hystero-laparoscopy were performed to determine etiological factors.

Ovarian causes were most prevalent (50%), followed by tubal (22.5%), uterine (20%), peritoneal (18.3%) and unexplained infertility (20%). Laparoscopic evaluation enhanced diagnostic clarity, revealing a high burden of ovarian abnorm alities, tubal blockages and peritoneal pathology including endometriosis and pelvic adhesions.

Infertility in this population demonstrated a heterogeneous etiological distribution dominated by ovarian, tubal and peritoneal factors. Comprehensi ve diagnostic evaluation is essential for individualized management and improved reproductive outcomes.

Infertility, tubal factor, laparoscopy, ovarian dysfunction

Infertility, defined as the inability to conceive after 12 months of regular unprotected intercourse, remains a significant global reproductive health issue affecting millions of couples. Recent estimates indicate that the worldwide 12 -month prevalence of infertility is approximately 17.5%, reflecting a substantial burd en on healthcare systems and families alike [1]. Global analyses from 1990 -2021 further show a rising trend in female -specific infertility, with notable regional variations driven by socioeconomic, environmental, and healthcare -access differences [2]. Female infertility arises from a diverse spectrum of etiological factors, including ovulatory disorders, tubal pathology, uterine abnormalities, endometriosis, endocrine dysfunction, infections, and unexplained causes. Studies have demonstrated that ovulatory dysfunctions particularly polycystic ovary syndrome (PCOS) are among the most common contributors to female infertility worldwide [3]. In addition, tubal factor infertility remains highly prevalent, especially in low - and middle -income countries where pelv ic inflammatory disease (PID), genital tuberculosis, and sexually transmitted infections continue to influence reproductive morbidity [4]. Uterine causes such as fibroids, intrauterine adhesions, and congenital anomalies also play a significant role in pre venting implantation or sustaining early pregnancy [5]. Endometriosis an inflammatory, estrogen-dependent condition can impair fertility through altered pelvic anatomy, chronic inflammation, and reduced ovarian reserve, affecting approximately 10% of reproductive-age women and nearly 50% of infertile women in some populations [6]. Notably, age has emerged as one of the strongest predictors of female fertility potential. A tertiary-care based analysis highlighted a steep decline in ovarian reserve and oocyte quality beyond the age of 35, significantly increasing the likelihood of infertility and need for assisted reproductive technologies [7]. Lifestyle -related factors such as obesity, smoking, stress, environmental endocrine disruptors, and delayed childbear ing have further compounded infertility rates in modern populations [8]. While global and regional data are widely available, etiological patterns often differ significantly across countries and within different levels of healthcare facilities. A 2023 tert iary-care study from Asia reported ovulatory disorders as the leading cause, followed by tubal factor infertility, International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 975 ~ endometriosis, and unexplained infertility, underscoring the need for local data to guide clinical services [9]. Another multi - institutional study emphasized that accurate identification of female-factor infertility improves diagnostic precision, ensures appropriate referrals, and enhances treatment outcomes especially in resource-limited settings [10]. Given the variability in etiological f actors and the influence of regional health dynamics, there is a need for updated, institution- specific data on the incidence and distribution of various causes of female infertility. Therefore, the present study aims to evaluate the incidence of different causes of infertility among women attending the gynaecology outpatient department (OPD) of a tertiary-care centre, helping to guide targeted diagnostic and management strategies for optimal reproductive outcomes.

This hospital -based observational study was conducted in the Department of Obstetrics and Gynaecology at a tertiary care centre over a defined study period. A total of 120 women presenting to the gynaecology outpatient department (OPD) with complaints of infertility were incl uded. Infertility was defined as the inability to conceive after at least 12 months of regular unprotected intercourse. Both primary and secondary infertility cases were enrolled after obtaining written informed consent. All eligible participants underwent detailed history taking, clinical examination, and appropriate investigations to identify etiological factors contributing to infertility. History included age, duration of infertility, menstrual pattern, obstetric history, medical and surgical history, p rior pelvic infections, contraceptive use, lifestyle factors and previous treatment for infertility. Clinical examination involved general physical assessment, body mass index calculation, and systemic examination with emphasis on thyroid, breast and pelvi c evaluation. Investigations were performed according to standardized departmental protocols. Ovulatory function was assessed through menstrual history, mid -luteal serum progesterone where necessary, and ultrasonographic evaluation of follicular development. Hormonal assays including thyroid -stimulating hormone (TSH), prolactin and, when indicated, serum androgens and anti -Müllerian hormone (AMH) were obtained. Pelvic ultrasonography was performed to identify ovarian morphology, uterine anomalies, endometrial thickness and adnexal pathology. Tubal patency was evaluated through hysterosalpingography (HSG), and laparoscopy was advised in selected cases where endometriosis, adhesions or tubal pathology required further confirmation. Uterine cavity abnormalities were assessed using transvaginal sonography and diagnostic hysteroscopy when required. Based on clinical findings and investigation results, the causes of infertility were categorised into ovulatory dysfunction, tubal factor, uterine factor, endometriosis, cervical factor, unexplained infertility, or mixed causes. Each participant was classified under the predominant etiological category. All collected data were systematically recorded in a predesigned proforma and subsequently entered into a spreadsheet f or analysis. Statistical analysis was performed using appropriate software. Descriptive statistics including frequency distribution and percentages were computed to determine the incidence of different causes of infertility within the study population.

were presented in tables and charts wherever applicable. Ethical approval was obtained from the institutional ethics committee prior to the commencement of the study.

A total of 120 women with infertility were included in the present study. O f these, 74 women (61.6%) presented with primary infertility and 46 women (38.4%) with secondary infertility. The distribution of etiological factors showed considerable overlap between the two groups, although certain patterns emerged on detailed evaluati on. As shown in Table 1, ovarian factor infertility constituted the largest category overall, affecting half of the study population. Among women with primary infertility, 54.05% exhibited ovarian dysfunction, whereas 43.47% of secondary infertility cases were attributed to ovarian causes. Tubal factor infertility accounted for 22.5% of all cases, with a relatively similar distribution between primary and secondary infertility. Uterine factor infertility contributed to 20% of cases, whereas peritoneal facto rs such as endometriosis, adhesions and pelvic pathology were responsible for 18%. Unexplained infertility continued to represent a significant proportion and was more common among secondary infertility patients at 28.26%, compared to 14.86% in primary infertility. Laparoscopic evaluation was performed in 94 women (78.3%), providing detailed information on intra -abdominal and pelvic pathology. The findings are presented in Table 2. Ovarian abnormalities were the most frequently detected pathology, identified in 40.42% of women who underwent laparoscopy. Polycystic ovarian morphology constituted the majority of ovarian findings and was more frequently observed among those with primary infertility. Tubal blockage was noted in 22.34% of cases, including bilater al block, unilateral block and hydrosalpinx. Peritoneal causes such as endometriosis, pelvic adhesions and genital tuberculosis contributed significantly to primary infertility, accounting for 25.53% of laparoscopic findings. Uterine pathology including fi broids, müllerian anomalies and hypoplastic uterus represented 11.7% of abnormalities. Hystero-laparoscopic correlation of etiological factors is summarized in Table 3. Ovarian factors remained the predominant cause (38.29%), followed by tubal factors (27.65%) and peritoneal factors (24.46%). Uterine causes contributed to 25.53% of cases, while unexplained infertility accounted for 22.34% of the evaluated women. This combined evaluation strengthened the diagnostic precision and highlighted the multifactorial nature of infertility among the study participants. Table 1: Causes of infertility (N = 120) Causes of infertility Primary (N=74) Number Primary % Secondary (N=46) Number Secondary % Total (N=120) Number Total % Ovarian factor 40 54.05 20 43.47 60 50.00 Tubal factor 17 22.97 10 21.73 27 22.50 Uterine factor 15 20.27 9 19.56 24 20.00 Peritoneal factor 15 20.27 7 15.21 22 18.33 Unexplained 11 14.86 13 28.26 24 20.00 International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 976 ~ Table 2: Laparoscopically identified pathology of infertility (N = 94) Causes of infertility Primary (N=58) Frequency (%) Secondary (N=36) Frequency (%) Total (N=94) Frequency (%) Ovarian factor PCOS 14 (24.13) 7 (19.44) 21 (22.34) Simple cyst 1 (1.72) 1 (2.78) 2 (2.12) Chocolate cyst 5 (8.62) 1 (2.78) 6 (6.38) Complex cyst 5 (8.62) 1 (2.78) 6 (6.38) Streak ovaries 1 (1.72) 0 1 (1.06) Total ovarian 26 (44.82) 10 (27.78) 38 (40.42) Tubal factor Bilateral block 9 (15.51) 3 (8.33) 12 (12.76) Unilateral block 3 (5.17) 6 (16.67) 9 (9.57) Hydrosalpinx 0 2 (5.56) 2 (2.12) Total tubal 12 (20.68) 11 (30.56) 23 (24.46) Uterine factor Fibroid 3 (5.17) 2 (5.56) 5 (5.31) Mullerian anomaly 2 (3.44) 1 (2.78) 3 (3.19) Hypoplastic uterus 1 (1.72) 0 1 (1.06) Total uterine 6 (10.34) 3 (8.33) 9 (9.57) Peritoneal factor Endometriosis 5 (8.62) 4 (11.11) 9 (9.57) Pelvic adhesions 4 (6.89) 2 (5.56) 6 (6.38) Tuberculosis 5 (8.62) 0 5 (5.31) Total peritoneal 14 (24.13) 6 (16.67) 20 (21.27) Table 3: Hystero-laparoscopically identified causative factors of infertility (N = 94) Causes of infertility Primary (N=58) Number Primary % Secondary (N=36) Number Secondary % Total (N=94) Number Total % Uterine factor 15 25.86 8 22.22 23 24.46 Tubal factor 15 25.86 11 30.56 26 27.65 Ovarian factor 26 44.82 10 27.78 36 38.29 Peritoneal factor 14 24.13 6 16.67 20 21.27 Unexplained 11 18.96 10 27.78 21 22.34

The present study examined the distribution of etiological factors contributing to infertility among women attending a tertiary-care gynaecology outpatient department. The findings reaffirm the multifactorial nature of infertility, with ovarian, tubal, uterine and peritoneal pathologies contributing substantially to both primary and secondary infertility. Ovarian dysfunction emerged as the leading cause, consistent with global evidence showing that ovulatory disorders particularly PCOS remain the most frequent contributor to female infertility in reproductive-age women [11]. In recent literature, ovulatory dysfunction has been closely associated with metabolic disturbances, chroni c anovulation and endocrine dysregulation, which collectively impair fecundity and contribute to the rising burden of infertility in younger age groups [12]. Tubal factor infertility accounted for more than one -fourth of cases on combined hystero-laparoscopic evaluation. This finding aligns with contemporary studies demonstrating that tubal pathology continues to be a major cause of infertility, especially in populations with high prevalence of pelvic inflammatory disease, post -infectious sequelae and delay in seeking gynecological care [13]. Laparoscopic assessment remains the gold standard for accurate identification of tubal blockages, hydrosalpinx and peritubal adhesions, as imaging alone frequently underestimates the extent of tubal damage. Peritoneal causes including endometriosis, pelvic adhesions and genital tuberculosis were also significant contributors. Endometriosis, identified in nearly 10% of women, is known to reduce fecundity through a combination of pelvic inflammation, altered immunologic en vironment and mechanical distortion of pelvic structures. Recent evidence emphasizes that even minimal-to-mild endometriosis significantly affects reproductive potential and requires targeted management to improve conception rates [14]. Genital tuberculosi s, although less frequent globally, remains a notable contributor in South Asian populations, and its diagnosis is frequently delayed due to subtle or absent clinical symptoms. Uterine factors such as fibroids, congenital malformations and hypoplastic uter us accounted for over 20% of cases in the present study. According to recent literature, uterine anomalies demonstrate varying degrees of impact on fertility depending on the location, size and distortion of the endometrial cavity [15]. Fibroids impinging upon the cavity, in particular, are associated with implantation failure and increased miscarriage risk. Unexplained infertility constituted a considerable proportion of cases, especially among secondary infertility patients. This category reflects the lim itations of current diagnostic modalities and the complex interplay of endometrial receptivity, immunological factors and subtle ovulatory defects. As emphasized in recent reviews, unexplained infertility underscores the need for advanced diagnostic tools and individualized treatment approaches [12]. Overall, the findings of this study resonate with recent global trends indicating that infertility remains a heterogeneous condition requiring comprehensive evaluation. The integration of clinical assessment, h ormonal profiling, transvaginal ultrasonography and diagnostic laparoscopy improves diagnostic accuracy and allows for targeted management. The high proportion of ovarian and tubal pathology in this population highlights the importance of early detection, lifestyle modification, infection prevention strategies and timely referral to specialized infertility services.

Female infertility in this tertiary -care population was predominantly attributed to ovarian, tubal and peritoneal International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 977 ~ factors, with a noticeable contribution from uterine abnormalities and unexplained causes. Laparoscopic evaluation significantly enhanced diagnostic precision, identifying multiple coexisting pathologies not detectable through routine imaging. These findings highlight the complex and multifactorial nature of infertility and emphasize the need for early, comprehensive, and individualized evaluation. Strengthening diagnostic facilities and awareness among reproductive -age women may improve fertility outcomes and reduce long-term reproductive morbidity.  Conflict of interest: No! Conflict of interest is found elsewhere considering this work.  Source of Funding: T here was no financial support concerning this work

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