PART 1

CHAPTER XI

THE PREVALENCE AND FACTORS ASSOCIATED WITH INFERTILITY

1.11.1.  Definitions

Involuntary infertility is a social and medical priority worldwide problem. It receives the attention of different categories of investigators, including clinicians, epidemiologists, sociologists and demographers. Subsequently, different definitions and diagnostic criteria are often used, which complicate comparative assessment. Most authorities refer to the term “sterility” as the inability of a man to produce offspring. “Functionally sterile” is defined as having a sperm count below 20 million per milliliter of semen. The term “infertility” refers to a diminished (or absent) capacity to produce offspring where the possibility of achieving conception is not completely ruled out. According to the WHO definitions, “infertility”, whether male or female, can be defined as the inability of a couple to achieve conception after a year or more of regular, unprotected intercourse. Conception normally is achieved within twelve months in 80-85% of couples who use no contraceptive measures. After this time the couple should be regarded as possibly infertile and should be evaluated.

In many epidemiological studies, however, including those conducted by the WHO, infertility is define as the inability to conceive despite cohabitation and exposure to the risk of pregnancy for a period of 2 or more years. For further analytical purposes and in order to obtain comparable data, we have also adopted this definition. Couples who were unable to achieve conception after exposure to the risk of pregnancy for a period of 24 or more months were defined as “infertile”. We classified as “sub-fertile” those couples, who were unable to achieve a pregnancy after the period from 12 to 23 months of unprotected intercourse. The “primary sub-fertility/infertility” means that conception was never achieved, while the “secondary sub-fertility/infertility” means that female partner had previously conceived, but was subsequently unable despite exposure to the risk of pregnancy during above specified time-interval.

1.11.2. The Prevalence

World-wide estimates:

Worldwide, it is estimated that one couple in six experiences some form of infertility. The information on the prevalence of infertility in different countries is not widely available. Among important sources of information are community prevalence surveys, which have been carried out in limited locations. The WHO has been encouraging these studies and has developed a standardized protocol and a core questionnaire for this purpose.  Although estimates of prevalence are not very accurate and vary from region to region, about 8-10% of couples experience some form of subfertility during their reproductive lives. It seems likely that a certain number of all couples will remain infertile for a combination of unexplained reasons that are difficult to diagnose. Superimposed on this “core” of infertility may be additional factors that increase the prevalence of infertility in some communities. It is estimated that with additional factors for acquired infertility present, the prevalence could reach about 30% or even more.

Prevalence in Armenia:

The first WHO supported epidemiological survey on infertility in Armenia was carried out in1989 -1990 in more than 4000 married women of reproductive age living in the capital city of  Yerevan. It revealed that the primary infertility rate was 3.2% and the secondary infertility was 21.4%.

The results of the present very nation-wide survey on infertility in men, which is the first in Armenia, show that the prevalence rate is still quite high. The prevalence rate of total infertility, including sub-fertility, is 18.5% in this sample. The rate of the primary infertility (including sub-fertility) is 3.4% and of secondary infertility is 15.2% (Figure 1.11.1.).

Figure 1.11.2. demonstrates the percentage distribution of respondents, according to all fertility sub-categories. Thirty-eight men (2.7%) were classified as primarily infertile since they never achieved conception in sex partners despite cohabitation and exposure to the risk of pregnancy for a period of 2 or more years. Nine men (0.6%), whose sex partners never conceived during more than 1 year, but less than 2 years of unprotected sexual intercourse, were defined as primarily sub-fertile. One hundred and forty-five men (10.4%) were secondarily infertile and sixty-eight (4.9%) were secondarily sub-fertile.

Forty-two out of 47 primarily sub-fertile or infertile men (89%) had involuntary infertility, since they were trying to have offspring without success despite cohabitation for a period of at least one year. The remaining 5 men (11%) did not want to have children and were happy with their infertility. The proportion of involuntary infertility among 213 secondarily sub-fertile or infertile men was also quite high (86%). Twenty-nine (14%) of them, however, did not want to have another child.

1.11.3. The Gender-related Causes

World-wide estimates:

Infertility may be attributed to a cause either in one or both partners, but in many cases no cause can be identified. The incidence of infertility in men and women is almost identical, between 30 and 40%. Infertility is exclusively a female problem in 30-40% of the cases and exclusively a male problem in 10-30% of cases. In about 15-30% of infertile couples causes were diagnosed in both partners. After thorough medical investigations, the causes of the infertility remain unexplained in about 5-10% of infertile couples. Research shows that male infertility has increased over the past 40 years. About 0.5% of men were functionally sterile in 1938. Today functional sterility has reached between 8-12% (more than 15-fold increase).

Specific causes of infertility in male partners are commonly related to a defect in the production of sperm or to a block in sperm transport from the testis in preparation for ejaculation. The frequency of infection-related diagnosis in infertile men is relatively low, however, a history of STDs in the male partner increases the risk of an infection related diagnosis in the female partner causing the long-term infertility. Unfortunately, at least 25-40% of infertile men have idiopathic infertility, for which no cause can be identified.

Beliefs of the respondents about the gender-related causes of infertility:

In many societies, the ability to have children is an important sign of a man’s worth. Infertility is considered as exclusively a female problem, and the failure to have children is often seen as a social disgrace or cause for divorce. This survey demonstrates that although most of the respondents of this survey (87%) were aware that infertility is not exclusively a female problem, still 6% of men had contrary idea and 7% had no idea about this issue (Figure 1.11.3.).

Most of the survey respondents (94%) were sure that they are able to produce offspring (Figure 1.11.4.), however 83 men have had contrary beliefs (2%) or were not sure (4%). The most important reasons for such negative beliefs are shown in Table 1.11.1.

More than 19% out of 260 men with impaired fertility supposed that the causes of infertility are related exclusively to their partners (Figure 1.11.5.). Almost 9% believed that the causes of infertility are related only to their own sexual health problems and 4% had an opinion that the causes are in both partners. However, the great majority of men with impaired fertility (68%) were not  aware of the cause.

1.11.4. Diagnosed Causes

Gender-related diagnosed causes:

Only in 82 out of 260 cases (31%) with impaired fertility had at least one partner sought out medical investigation. In about 26% of investigated couples the causes of infertility were found only in male partners and in 17% they were found in both (Figure 1.11.6.). In total, the causes of male infertility were diagnosed in 42.7% of couples, and female infertility in 58.5%.

Specific causes of male infertility:

Available information suggests that the most common causes of male infertility are: 1) sperm production disorders affecting the quality and/or the quantity of sperm, 2) anatomical obstructions, and 3) other factors, such as immunological disorders and sexual dysfunction. In this survey sample, only in 60 men with impaired fertility was semen analysis ever performed (23%). In 50 % of these cases, results of the semen investigation indicated the presence of some abnormality (Figure 1.11.7.). Although semen analysis is not a test of fertility, a carefully performed semen analysis is a highly predictive indicator of the hormonal status of the male reproductive system, spermatogenesis and the patency of the reproductive tract.

Overview of the research studies shows that about 20% of infertile men have sexual dysfunction. Decreased sexual drive, erectile dysfunction, premature ejaculation and failure of intromission are all potentially correctable causes of reproductive failure.  In this survey, 41 out of 1400 men (3%) reported sexual dysfunction (Figure 1.11.8.). The most frequently mentioned suspected reasons for dysfunction were stress or anxiety (34%), genito-urinary infections, including STDs (15%), and injuries of genitals (2%). In a large proportion of cases sexual or ejaculatory disturbances started at a relatively younger age (Table 1.11.2.).

There was a direct relationship found in this study between fertility and sexual function in men: the large majority of men with sexual and ejaculatory dysfunction (63%) were either primarily or secondarily infertile (Figure 1.11.9.).

A higher proportion of respondents with impaired fertility reported inadequate erection, as compared with fertile men (9% versus 1%, p<0.000). The proportion of respondents who were suffering from impotence was also significantly higher among the infertile, as compared to fertile men (2.3% versus 0.2%, p<0.000).  

Based on the replies of respondents, we assumed that the most frequently diagnosed causes of the male infertility were the following (Table1.11.3.): 1) abnormal quality or the quantity of sperm (50%), sexual dysfunction (11%), varicocele (11%), male accessory gland infection (6%), and endocrine disorders (3.5%).

A review of the scientific literature shows that scrotal varicocele is the most common causative finding in infertile men. Most authorities now agree upon the casual relationship between varicocele and male subfertility. The reported incidence of varicocele in a random adolescent population is situated between 8 and 16%, whereas this affection is found in 30 to 40% of male partners in barren marriages. 

In this study, in the sample of 65 infertile men only 7 (10.7%) have been diagnosed with a varicocele. The low incidence of varicocele in Armenian men with impaired fertility may be related to the lack of diagnosis and respondent’s bias. This observation also suggests the need of further clinical investigation.

Specific causes of female infertility:

Results of WHO supported studies, that were based on the standardized methodology for investigation and diagnosis of infertile couples, show that the most common causes of female infertility are ovulatory disorders and anatomical abnormalities, such as damaged fallopian tubes.  In this survey 80 respondents with impaired fertility were aware of the causes diagnosed in their partners. The most frequently were mentioned the following causes (Table 1.11.4.).

1.11.5. Background Factors

Available research data show that some environmental factors, such as cigarette use, excessive alcohol consumption, and drug abuse decrease fertility in males. This study found that the proportion of smokers was significantly higher (p<0.00) among men with primary sub-fertility/infertility (85%), as compared to fertile men (78%). The occasional use of narcotic drugs or drug abuse was also more common for men with primary sub-fertility/infertility, than in fertile men (6.4% versus 3.3%, p<0.00). The proportion of men with the harmful habit of excessive alcohol consumption, however, was almost identical in all fertility categories.

Common sexually transmitted organisms such as Chlamydia trachomatis, Mycoplasma hominis and Ureaplasma urealyticulum have been implicated in reproductive failure in animals and humans .  This study revealed that the history of chlamydial infection was more common for infertile men (4.6%), as compared to the fertile (1.7%, p<0.00). A strong relationship was found between a history of Gonorrhea and infertility. The history of Gonorrhea was more common for men with impaired fertility, than in the fertile men (11.5% versus 6.9%, p<0.00).  

For many couples infertility is a hard condition to cope with psychologically. Both partners are often depressed and need not only physical but also emotional care. Historically, unexplained infertility was considered to have emotional causes, but as more and more physical problems were found, the emphasis has been on infertility as a cause of stress. Figure 1.11.10. demonstrates psychological conditions of male and female partners that suffer from involuntary infertility.

Beyond the medical expertise and advice as to how to overcome barriers to conception, infertile couples are looking for emotional support. In fact, the diagnosis and treatment of infertility itself also gives rise to high levels of stress. Many couples with long-term infertility repeatedly apply to different health providers or traditional healers, and are exposed to an enormous amount of unnecessary laboratory tests and medical interventions with potential adverse psychological outcome.

Some men describe that the inability to have children is disturbing interpersonal family relationships, while others find themselves as closer through the experience. Table 1.11.5. demonstrates that infertile men describe worse relationships with their wife’s parents than with their spouses and other relatives.

1.11.6. Access to Medical Care

Management of infertility includes investigation, diagnosis, treatment, if needed, and follow-up counseling of both partners. Some categories of infertile patients, particularly men with sexual dysfunction, usually have a fear of investigation or feel shy to speak about this issue. We found that the majority (54%) of respondents with sexual or ejaculatory dysfunction never applied for medical counseling and care. The main reasons for not applying are described in the Table 1.11.6.

In the large majority of cases with impaired fertility (68.5%) neither partner applied for investigation and reproductive health care (Figure 1.11.11.).

Almost one third of men (32%) preferred to wait until spontaneous conception, 26% felt shy at the prospect of being medically investigated, about 16% had completed their family formation, and 8% had no means to cover the expenses for infertility care (Table 1.11.7.).

In total, only 65 out of 260 (25%) men with impaired fertility ever applied for infertility investigation and care. Most of them went to a specialized health center, however, some went to facilities that are not specialized for the investigation and diagnosis of infertile men (Table 1.11.8.).

Only 24 out of 65 investigated male partners (37%) and 45 of 80 female partners (56%) received treatment for infertility (Figure 1.11.12.).

Seven out of 65 (11%) men, who applied for infertility care, had genito-urinary surgery (because of varicocele, cryptorchidism, or urethral stricture). In two of those 7 men (29%), however, the surgery was complicated. 

For a significant number of infertile couples, investigation and treatment was rather complicated or unaffordable (Figure 1.11.13.).

As demonstrated in Figure 1.11.13, more than 46% of respondents had financial difficulties, 12% had difficulties in finding prescribed medicines, and 8% were living far away from a health facility.  Among the startling observations of this survey was the fact that about 5% of men had an opinion that health providers lack counseling and clinical skills for infertility management.