Prevalence and Etiological Pattern of Infertility in Women Presenting to a Gynecology Clinic in a Secondary Health Facility, South-South, Nigeria: A Cross-Sectional Study

Over the one year of the study, a total of 832 new patients attended the Gynaecology clinic, with 286 diagnosed with infertility, giving a prevalence rate of 34.4%. Only 206 patients completed their fertility assessment and were included in the analysis. ( Figure 1 ) Schematic flowchart illustrating the recruitment of participants The average age of participants was 32.5 ± 5.8 years, with a minimum age of 20 and a maximum of 50 years. Most participants were in the age groups of 20-30 and 31-40 years, accounting for 39.8% and 49.0%, respectively. Only 2 (1%) patients were under 20 years old. Only 16.5% of participants had previously delivered a baby. The majority were Ika indigenes, at 159 (77.2%), followed by Ibos at 20 (9.7%), and other tribes at 27 (13.1%). The literacy level was high, with 97.1% having attained education beyond primary school. Small-scale business owners comprised the largest group, with 139 (67.5%) participants, while artisans and civil servants represented 42 (20.4%) and 20 (9.7%) participants, respectively. Most participants, 136 (66.0%), reported an infertility duration of less than 5 years ( Table 1 ). Sociodemographic and Obstetric Characteristics of participants Pie chart showing the distribution of Primary and Secondary Infertility Primary infertility was seen in 85 (41.3%) participants, while secondary infertility was noted in 121 (58.7%). ( Figure 1 ) Male factor infertility was the highest, 77 (37.4%), followed by female factor infertility at 68 (33.0%). Combined male and female factor infertility was 33 (16.0%), while the factor associated with infertility was unexplained in 28 (13.6%) of the patients. (Fig 3) Pie Chart of the factors associated with Infertility Fig 4 shows that the commonest factor associated with infertility among the female patients was bilateral tubal blockage, 40 (19.4%). Anovulation, endometriosis, uterine fibroids and uterine synechiae were implicated in 29 (14.1%), 20(9.7%), 18 (8.7%) and 8(3.9%), respectively. Bar chart showing the factors associated with female infertility among the participants

Study area: CHA was established in 1906. It is a 250-bed hospital located in the South-South region of Nigeria. It provides general medical care and specialist services to indigenes of Delta State and neighboring parts of Edo State. The Obstetrics and Gynaecology department is staffed by two consultant fellows of the West African College of Surgeons and the National Postgraduate Medical College of Nigeria. Additionally, medical officers and House officers assist in the department's operations. The gynaecology clinic holds sessions twice weekly. Study design: This was a quantitative cross-sectional study conducted at the Gynaecology clinic of CHA, Delta State, Nigeria, between January 1st and December 31 st , 2024 The study included women presenting to the gynaecology clinic with a history of infertility lasting one year or more, who consented to participate. Most patients were referred from the general outpatient clinic, with some coming from private health facilities. They were managed in the gynaecology clinic, where basic investigations were conducted: seminal fluid analysis, pelvic scan, hysterosalpingogram, and ovulation assessment (follicle tracking and/or Mid-luteal phase progesterone). Only patients who completed these investigations were included in the study. Women who presented for fertility treatment completed their tests and gave consent to participate. Couples (male or female) who did not complete their investigation Those who did not give consent Data collection: A data collection form was adapted from a previous study by Odunvbun et al and used to gather information. [ 13 ] The form had two parts: Section A covered socio-demographic, gynecological, and obstetric histories, while Section B documented the investigation results and factors associated with infertility. Three trained clinic staff assisted with questionnaire administration and result documentation. Eligible women were informed about the study, and consent was obtained. A consecutive sampling method was used to recruit all eligible women (n = 206) between January 1, 2024, and December 31, 2024. Ethical clearance: The study protocol was approved by the hospital's Ethical Committee with ethical no AMZ/CHA/20/11/23/0016. Recruitment of study participants was voluntary, based on verbal briefings in English, pidgin English, or the local languages, as appropriate. The study was executed under the guidelines of the Declaration of Helsinki, 2013. The authors are available and ready to supply the data on request Data analysis: The data generated were analyzed using IBM SPSS Statistics version 25. The sociodemographic and obstetric characteristics were analysed and presented with descriptive statistics, including frequencies, percentages, and means with standard deviations, displayed in tables. A pie chart was used to display the proportion of women with primary and secondary infertility and also the distribution of factors associated with infertility, while a bar chart was used to display the distribution of female factors observed. Male infertility: Seminal fluid analysis was done in the hospital laboratory, adopting standard operating procedures. WHO 6 th edition for SFA analysis was used to classify abnormality Anovulation: Anovulation was defined as the failure to demonstrate a dominant follicle on serial transvaginal scan (TVS) and/or mid-luteal phase progesterone levels < 3ng/ml Polycystic ovary syndrome was defined based on the Rotterdam criteria Endometriosis was diagnosed using TVS complemented with abdominal ultrasound when necessary.

Infertility is a significant clinical problem among women presenting to a secondary-level gynecology clinic in South-South Nigeria. In this cohort, male-factor infertility was the leading contributor (37.4%), underscoring the need for early involvement of the male partner in the routine fertility assessment. Preventive strategies, particularly sexually transmitted disease prevention, prompt treatment of reproductive tract infections, post abortion care, and community education, remain critical.

The study evaluated the prevalence and etiological pattern of infertility in women attending a gynecology clinic at a secondary healthcare facility. Since infertility has become a major health concern worldwide, documenting its prevalence and associated factors, especially in a semi-urban setting like ours, is essential. The prevalence of infertility found in the study was 34.4%. This result is similar to the report by Odunbun et al [ 13 ], which showed an infertility prevalence of 32.0%.[ 13 ]It is higher than the 18.2% reported by Oriji et al [ 14 ] and the 26.8% reported by Oguijiofor et al. [ 21 ]. In a systematic review by Abebe et al. [ 29 ], the pooled fertility prevalence in Africa was 49.9%. The high rate of infertility found in this study may be related to poor access to reproductive health services. Sexual health education and counseling, and proper gynaecological care for female reproductive tract infections are not readily available in semi-urban health centers compared to the urban health centres, resulting in a high prevalence of tubal damage and infertility subsequently. Women who had spontaneous abortions or induced abortions may not have readily available post abortion care services, with the resultant high propensity for tubal damage from untrained providers. Additionally, the previous studies employed a retrospective approach; therefore, the possibility of missing data and data inconsistencies cannot be ruled out in those studies. Secondary infertility was higher than primary infertility in this study. The finding aligns with previous studies.[ 13 , 14 , 21 , 30 ] Deshpande et al [ 31 ] and Signhet al.[ 32 ], both in India, reported primary infertility rates of 57.5% and 68.0%, respectively, while Madziyire et al.[ 33 ] in Harare, Zimbabwe, reported a 75% rate of primary infertility in their review. Generally, primary infertility is more common in developed countries, while the secondary infertility rate is high in Sub-Saharan Africa, and the primary underlying cause has been attributed to infections, particularly sexually transmitted infections (STIs). [ 34 , 35 ] The commonest cause of infertility was male factor, 37.4%, while female factor was 33.0%. Combined and unexplained factors were the next most common factors. The finding is similar to that by Odunvbun et al.[ 13 ] In the Gambia, a review of the trajectories of infertility showed that the male factor contributed 45.4%.[ 36 ] In the review by Oriji et al[ 14 ] and Ogujiפור et al [ 21 ], female factors were the most prevalent causes of infertility. The higher rate of male infertility in our study may be a result of lifestyle modification among the male population, with the increasing use of illicit drugs, alcohol consumption, and cigarette smoking. Although this remains at the hypothesis level, as this study was not designed to assess that, clinically, it highlights the need for mandatory seminal fluid analysis early in the evaluation of infertility. The most common female factor associated with infertility was tubal disease. This finding aligns with previous studies. [ 13 , 14 , 21 ] Deshpande in India identified polycystic ovary syndrome as the leading cause of infertility in their research.[ 31 ] The consistent identification of tubal disease as a major cause of female infertility and a significant contributor to secondary infertility, especially in the Sub-Saharan African region, underscores the need for more effective reproductive health services. Preventing and treating sexually transmitted infections, along with improved post-abortion care and efficient family planning services, will greatly help reduce the high prevalence of tubal factor infertility. Polycystic ovary disease (PCOD) remains a significant cause of anovulation among infertile women, with a reported prevalence of 18%. [ 37 , 38 ] PCOD was responsible for female infertility in 14.1% of the participants. This is lower than the 46% contribution recorded by Deshpande et al [ 31 ] in India and 28% recorded by Odunvbun et al.[ 13 ] It is slightly lower than the 16% contribution in the Zimbabwe study but higher than the 11.2% by Oriji et al.[ 14 ] The wide variation in the various studies may be related to the lack of uniform criteria for PCOD diagnosis, the overlapping of symptoms with other medical conditions, and the limited access to diagnostic tools like TVS and the availability and cost of hormonal assays in the various study areas. Endometriosis was once assumed to be rare among African women, but recent studies suggest that the incidence could be as high as 48.1%.[ 39 ] TVS complemented with abdominal ultrasound was used for the diagnosis of endometriosis in this study. The improvements and availability of high-definition ultrasounds have improved the diagnosis of endometriosis. Recent updated guidelines from the European Society of Human Reproduction and Embryology (ESHRE) [ 40 ] suggest that imaging techniques, particularly TVS, should replace laparoscopy as the first-line investigation tool for suspected endometriosis due to its superior feasibility, ease of access and diagnostic accuracy. The ESHRE guidelines suggest that laparoscopy should only be used for diagnosis when imaging results are inconclusive, as ultrasound is unable to exclude all subtypes of endometriosis, especially peritoneal endometriosis.[ 40 - 42 ] Through varying mechanisms, endometriosis remains a significant contributor to infertility. Uterine fibroids are not typically considered a primary cause of infertility. Instead, they are often seen as an incidental finding, where the link to infertility is more coincidental than directly causal.[ 43 ] In other words, fibroids might be blamed for infertility when no other underlying cause is identified. Strengths and Limitations: This pioneering study provides baseline data on infertility in the institution and surrounding community. However, 80 of 286 couples did not complete investigations, potentially affecting findings. Limitations include its single-centre, cross-sectional design and clinic-based sample. Larger multicentre studies are recommended. Endometriosis diagnosis relied on TVS; combining TVS with laparoscopy could improve detection, particularly of peritoneal lesions.

Infertility is a disease of the male or female reproductive system characterized by the inability to achieve pregnancy after 12 months or more of regular unprotected sexual intercourse.[ 1 ] It affects millions worldwide, often resulting in serious consequences. In many cultures, the ability to conceive is seen as a fundamental purpose of marriage, making infertility a major cause of emotional pain for couples.[ 2 ] Addressing infertility is vital for protecting sexual and reproductive health and rights; however, many countries still lack adequate policies and services to support those affected. It is a widespread health concern, affecting an estimated 8-15% of couples worldwide.[ 3 , 4 ] It is estimated that 48 million couples and up to 186 million individuals are living with infertility globally, with roughly half of the affected couples residing in Sub-Saharan Africa and South Asia.[ 5 ] Using data from 1990 to 2021, the 2022 global infertility prevalence estimates show that approximately 1 in 6 people has experienced infertility at some point in their lives, with a lifetime prevalence of 17.5%[ 1 ]. A systematic review of 277 health surveys found that approximately one in four couples in low- and middle-income countries (LMICs) were affected by infertility.[ 6 ] In terms of regional prevalence, the African region had the highest period prevalence of infertility in 2019, at 16.4%, followed by the Western Pacific (13%) and European (12.4%) regions.[ 6 ] According to a recent secondary analysis of Demographic and Health Surveys (DHS) from 16 countries in sub-Saharan Africa and Southern Asia, primary infertility prevalence was relatively low, ranging from 0.3% in Kenya to 0.8% in Uganda, 3.8% in Senegal, and 2% in Nigeria.[ 7 ] The overall prevalence of primary and secondary infertility across these 16 countries was 2% and 19%, respectively.[ 7 ] In Nigeria, various prevalence rates have been reported in various regions. Obuna et al. [ 8 ], Menuba et al,[ 9 ], and Nwajiaku et al[ 10 ] (all from South-East Nigeria) reported rates of 15.4%, 12.1%, and 18.5%, respectively. Adegbola and Akindele [ 11 ] in South-West Nigeria reported a rate of 26.8%, while Dattijo et al. [ 12 ] in Bauchi, Northern Nigeria, reported a rate of 23.9%. Odunvbun et al. [ 13 ] and Oriji et al. [ 14 ] in South-South Nigeria reported rates of 32.0% and 18.2%, respectively. 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.[ 15 ] Infertility is categorized into primary and secondary. Primary infertility refers to a situation where a couple has never achieved conception despite having regular, unprotected sex for at least 12 months, whereas secondary infertility occurs when a couple is unable to conceive again despite adequate unprotected sexual activity for at least 12 months, following a previous pregnancy.[ 16 ] While primary infertility is more prevalent in other parts of the world, secondary infertility is a significant concern in Africa, where it is more common.[ 17 , 18 ] This high incidence is often a direct result of poorly managed pelvic inflammatory disease, which can lead to utero-tubal damage and pelvic adhesions. Complications from unsafe abortions and puerperal sepsis also contribute significantly.[ 10 ] In Nigeria, for example, infertility is predominantly secondary and primarily driven by infections, including sexually transmitted infections (STIs), post-abortal sepsis, and puerperal sepsis.[ 18 ] The causes of infertility among couples are attributed as follows: male factors account for 30-40%, female factors for 30-40%, combined factors for 10-20%, and approximately 5-10% of cases remain unexplained.[ 12 , 19 , 20 ] The distribution of factors associated with infertility, as detailed in a review by Odunvbun et al, showed male infertility at 40.6%, female infertility at 31.6%, combined factors at 15.6%, and unexplained factors at 12.7%.[ 13 ] In a five-year retrospective cross-sectional study conducted by Oguejiofor et al at Nnamdi Azikiwe University Teaching Hospital in Nnewi, Nigeria, the reported pattern of infertility was as follows: male factors constituted 11.7%, female factors 45.3%, combined male and female factors 38.0%, and unexplained factors 5.0%.[ 21 ] Oriji et al in Bayelsa reported male infertility alone at 19.2%, female causes alone at 54.0%, combined causes at 24.1%, and unexplained factors at 2.7%.[ 14 ] The differences in the reported causes of infertility even within the same region could be due to multiple factors, including demographic differences, access to healthcare and fertility management, cultural and social reasons, and variations in data collection and reporting. Among the female participants, factors identified to be responsible for infertility include tubal blockage, hydrosalpinx, peritubal adhesions, intrauterine adhesions, polycystic ovary disease, and ovarian insufficiency.[ 13 , 14 , 21 ] Tubal blockage was consistently the most common factor associated with female infertility.[ 13 , 14 , 21 ] In many African cultures, having children is fundamental to one's identity and social standing, with motherhood seen as a key indicator of marital success.[ 22 , 23 ] Infertility challenges these societal norms, and women typically bear the weight of the stigma. They may be held responsible for the issue, viewed as inadequate, and face ridicule or abandonment.[ 23 , 24 ] As a result, marital problems often arise, with infertile women frequently experiencing rejection or finding themselves in polygamous marriages as their partners seek to have children.[ 25 , 26 ] Men, while less openly stigmatized, may also suffer in silence due to societal pressures to prove their masculinity and fertility.[ 27 , 28 ] Understanding infertility patterns in South-South Nigeria is essential for targeted reproductive health interventions. Despite substantial psychosocial challenges and limited regional data, particularly from secondary health facilities, the burden and causes remain poorly defined. This study aimed to determine the prevalence and etiological pattern of infertility among women attending a secondary health facility, providing evidence to guide clinical services, policies, prevention, and treatment strategies.