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Aetiology of Infertility: An Epidemiological Study

Simmi Oberoi1, Ravinder Khaira1, Sunvir Kaur Rai2

Financial Support: None declared

Conflict of Interest: None declared
ABSTRACT
Copy Right: The Journal retains the
copyrights of this article. However, re- Introduction: In a social set-up as existing in Indian subcontinent,
production of this article in the part or with a strong emphasis on child-bearing; infertility manifests as a
total in any form is permissible with condition with psychological, economic and medical implications
due acknowledgement of the source. resulting in trauma and stress.

How to cite this article: Rates of infertility varied widely among the different states of In-
Oberoi S, Khaira R, Rai SK. Aetiology dia viz. 3.7 per cent in Uttar Pradesh, Himachal Pradesh and Ma-
of Infertility: An Epidemiological harashtra, to 5 per cent in Andhra Pradesh, and 15 per cent in
Study. Ntl J Community Med 2017; Kashmir.
8(1):17-21.
As infertility plays vital role in post marital life, the present study
Author’s Affiliation: is aimed at identifying aetiology of infertility with special refer-
1Assistant Professor; 2Jr. Resident, Dept ence to genital tuberculosis as a causative.
of Community Medicine , Government
Medical College & Rajindra Hospital, Methods: Data obtained from patients visiting OPD related to de-
Patiala (Punjab) tailed history, clinical examination and records of previous inves-
tigations were considered for analysis.
Correspondence:
Dr. Simmi Oberoi
Results: In more than half of the infertility cases, duration of mar-
[email protected] riage was less than five years. Ovarian & tubal factors together
constitute 46.20% pitted against all other factors. Amongst male
Date of Submission: 15-09-16 aetiological factors, sperm-cervical mucus anti-sperm antibody fac-
Date of Acceptance: 07-01-17 tor was the top contributor in the whole list i.e. 59.67% while re-
Date of Publication: 31-01-17 maining 40.33% other defects in seminology were responsible.
Role of genital tuberculosis as a cause of infertility should be kept
in mind especially in endemic zones.
Conclusion: The present study highlights the fact that male factors
contribute predominantly for infertility though females are often
blamed and are at the receiving end in this region.
Keywords: Infertility, epidemiology, aetiology

INTRODUCTION ity manifests as a condition with psychological, eco-

nomic and medical implications resulting in trauma
As infertility plays vital role in post marital life
and stress.2
of Indian ladies, the present study is aimed at
identifying aetiology of infertility with special Infertility is categorised as primary and secondary
reference to genital tuberculosis as a causative. infertility and operational definition, put forth by the
WHO, defines primary infertility as the “When a
Beyond twelve or more months of regular un-
woman is unable to ever bear a child, either due to
protected sexual intercourse, if couple is unable
the inability to become pregnant or the inability to
to achieve the clinical pregnancy then it is
carry a pregnancy to a live birth she would be classi-
termed as infertility, a disease of reproductive
fied as having primary infertility. Thus women
system according to the International Committee
whose pregnancy spontaneously miscarries, or
for Monitoring Assisted Reproductive Technol-
whose pregnancy results in a still born child, without
ogy & World Health Organization (WHO).1 In a
ever having had a live birth would present with pri-
social set-up as existing in Indian subcontinent,
marily infertility.3 Secondary infertility refers to the
with a strong emphasis on child-bearing; infertil-
inability to conceive following a previous pregnancy.3

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Globally, most infertile couples suffer from pri- partment followed by the research committee of the
mary infertility.4The incidence of infertility in institution. Data related to detailed history, clinical
any community varies between 5 and 15 %.5 The examination & records of investigations were consid-
overall prevalence of primary infertility ranges ered for analysis. As all cases of infertility, consecu-
between 3.9% and 16.8%.6 tively were included for the duration of study period
of one year (248 infertility cases out of 8548 cases re-
In some parts of the globe including South Asia,
ported to Gynaecology OPD) sample size calculation
sub-Saharan Africa, the Middle East and North
was irrelevant. The results of study were statistically
Africa, Central and Eastern Europe and Central
interpreted to infer.
Asia, the rates of infertility reach up to 30 %.7 In-
fertility is estimated to affect as many as 186 mil-
lion people worldwide.7
RESULTS
Rates of infertility varied widely among the dif-
Present study highlighted the sincerity with which,
ferent states of India viz. 3.7 per cent in Uttar
affected have sought early medical help and interven-
Pradesh, Himachal Pradesh and Maharashtra, to
tion as cases reported under-five years make up the
5 per cent in Andhra Pradesh, and 15 per cent in
bulk of reported infertile couples. Statistically signifi-
Kashmir.8
cant association of infertility with duration of mar-
The aetiology of infertility can be grouped into riage was observed. The present study has thrown
male factors and female factors. In over 25% of light on the fact that, while female factors were re-
infertility cases, no detectable cause can be sponsible for a meagre quarter of cases; the other
traced after routine tests, which leaves the case quarter both male & female factors were responsible.
as unexplained infertility.2 Strikingly male factors alone were contributing to
half of the cases of infertility.
The role of laparoscopy in the diagnosis of pri-
mary and secondary infertility is established be-
yond any doubt.8 In the assessment of tubal and Table 1: Distribution of infertility according to du-
peritoneal factors leading to infertility, laparos- ration of marriage
copy is an initial diagnostic procedure. Laparos-
copy is a valuable procedure to obtain tissue for Age Primary Secondary Total cases
infertility Infertility
histo-pathological examination, or for mycobac-
0-5 years 111 (64.17) 24 (32.00) 135 (54.43)
terial culture and PCR.9 In many cases of genital
6-10 years 32 (18.50) 27 (36.00) 59 (23.79)
tuberculosis abnormal findings were seen in fal- 11-15 years 22 (12.70) 17 (22.67) 39 (15.73)
lopian tubes. 16-20 years 7 (4.05) 5 (6.67) 12 (4.84)
TB directly and / or indirectly affects female re- 21-25 years 1 (0.58) 2 (2.66) 3 (1.21)
productive health and Genital tuberculosis is an
important cause of sub fertility, especially in en- Table 2: Distribution of infertility cases by aetiolog-
demic zones such as South India. Because of lack ical factors (gender-wise)
of highly sensitive and specific tests the true ep- Aetiological Primary Secondary Combined
idemiology of this disease remains unknown. factors infertility infertility
Genital tuberculosis not only causes tubal ob- Female factors 44 (25.43) 20 (26.67) 64 (25.80)
struction and dysfunction but also impairs im- Male factors 89 (51.45) 35 (46.66) 124 (50.00)
plantation due to endometrial involvement and Both male & 40 (23.12) 20 (26.67) 60 (24.20)
female factors
ovulatory failure from ovarian involvement.10
In India, infertility manifests as social problem
Table 3: Distribution of female aetiological factors
where the females and not the males are solely
held responsible for this lifetime problem of hav- Aetiological Primary Secondary Total
ing no child.11 Factors infertility infertility
*Tubal 17 (13.28) 29 (51.79) 46 (25.00)
*Ovarian 34 (25.56) 5 (8.92) 39 (21.20)
Uterine 20 (15.63) 8 (14.29) 28 (15.21)
MATERIALS &METHODS
Genital tuberculosis 17 (13.28) 7 (12.50) 24 (13.04)
For a period of one year i.e,from January to De- Infections of lower 12 (9.38) 4 (7.14) 16 (8.70)
cember 2003 all patients of infertility visiting the genital tract
Obs & Gynae OPD from 8.00am to 2.30 pm of an Cervical 10 (7.81) 2 (3.57) 12 (6.52)
established tertiary care hospital of repute in Endometriosis 10 (7.81) 1 (1.79) 11 (5.98)
Thyroid/others 8 (6.25) 0 (0.0) 8 (4.35)
Punjab state of Northern India were subjected to
Total 128 (100) 56 (100) 184 (100)
a pretested proforma, the proforma was put to
*p<0.05, significant
validation by first the internal experts of the de-

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Table 4: Distribution of male aetiological fac- ries and 1 out of 7 cases had abnormal ovaries in sec-
tors in relation to infertility ondary infertility. On the other hand, 4 out of 17 cas-
Type of defect Primary Secondary Total
es of primary infertility had abnormal tubes while 3
infertility infertility out of 7 cases of secondary infertility had abnormal
Sperm cervical mucus 48 (57.14) 26 (65) 74(59.67) tubes.
antisperm antibody
Endometriosis was more in primary infertility as
factor
Asthenospermia 16 (19.05) 6 (15) 22(17.75)
compared to secondary infertility.
Oligospermia 12 (14.29) 1 (2.50) 13(10.48)
Azoospermia 6 (7.14) 4 (10) 10 (8.07)
Oligoasthenospermia 2 (2.38) 3 (7.5) 5 (4.03) DISCUSSION
Total 84 (100) 40 (100) 124 (100)
Findings of the present study as depicted in Table-1
are comparable to earlier reported data of Shilpa and
Table 5: Findings of diagnostic laparoscopy of Chethana regarding under-five year and even 5 to 10
primary and secondaryinfertility cases
year duration for primary infertility.12
Infertility Normal Abnormal
As more sophisticated and well established IVF cen-
Primary Infertility
Ovaries 41.02% 58.98% tres are in accessible vicinity. The persons from high-
Uterus 79.48% 20.52% er income group prefer to report there while majority
Fallopian tubes 61.53% 38.46% of poorer population report to government institu-
Spill 64.10% 35.90% tions.
Endometriosis 84.61% 15.39%
Secondary Infertility Data obtained in the present study are in consonance
Ovaries 56.52% 43.48% with a study conducted in Bangladesh by Sultana et
Uterus 91.30% 8.70% al13 as far as the shared responsibility by both the
Fallopian tubes 52.17% 47.83% sexes for the aetiology of infertility is concerned.
Spill 78.26% 21.74% Whereas the role of male in the present study strikes
Endometriosis 95.65% 4.35% a close similarity with data provided by Shamila and
Sasikala14 while the female factors is close to the fig-
Table 6: Findings of diagnostic laparoscopy in ures in the text book description as in Howkins &
genital tuberculosis Bourne Shaw’s textbook of gynaecology.4
Diagnostic Primary Secondary
part Normal Abnormal Normal Abnormal
Ovaries 3 1 3 1 Table 7: Published data vis-à-vis present study (ae-
Uterus 4 0 4 0 tiological factors-gender wise)
Fallopiantubes 0 4 1 3
Study Male Female Both Unex-
factors factors (%) plained
The highlighted feature is that ovarian & tubal (%) (%) (%)
Sultana et al 13 20 43.63 21.81 14.54
factors together constitute 46.20% pitted against
Shamila S, Sasikala SL1454.33 45.67
all other factors i.e. cervical, uterine, thyroid,
Howkins & bourne 33.33 33.33 33.33
endometriosis and genital tuberculosis. Interest- shaw’s textbook of gy-
ingly enough, majority of cases suffered from naecology.16th ed.4
ovarian factors (25,56%) amongst primary infer- Present study 50 25.80 24.20
tility cases, while it was tubal factors(51.79%) for
the secondary infertility which was put to test to Present study findings are in consonance with data
know the statistical significance. projected in Dewhurst’s textbook of obstetrics and
Amongst male infertility aetiological factors, gynaecology15 regarding tubal factors individually
sperm-cervical mucus anti-sperm antibody fac- viewed in primary and secondary infertility cases;
tor was the top contributor in the whole list i.e. whereas in relation to tubal factors in primary infer-
59.67% while remaining 40.33% other defects in tility the Kashmir study by Wani et al7 data is also as
seminology were responsible. close.

Laparoscopy confirmed certain aetiological fac- The tubal factors in toto in the current study (25%)
tors. 58.98% of cases abnormal findings were ob- and that reported by Thonneau et al16 (26%) are al-
served in ovaries amongst primary infertility most the same as in the Howkins & Bourne Shaw’s
cases while it was tubal (47.83%) in secondary textbook of gynaecology4 (25-30%).
infertility cases. Seminological studies done at Bangladesh by Sultana
Laparoscopy in genital TB revealed that 1 out of et al13 and present study findings are quite close.
17 cases of primary infertility had abnormal ova-

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Table 8: Published data vis-à-vis present study (female factors)

Study Primary infertility Secondary infertility
Ovarian factors % Tubal factors % Ovarian factors % Tubal factors %
Dewhurst's textbook of ob & Gy(7thed)15 15-20 40
Kashmir study by Wani et al 7 7.3* 18.3 22.2 27.7
Present study 25.56 13.28 8.92 51.79
* peritubal & periovarian adhesions
Table 9: Published data vis-à-vis present study(male factors)
OligoSpermia Asthenospermia AzooSpermia Oligo Sperm cervical Others% Low Abnormal
Decreased Decreased No sperms% Astheno mucus antis- volume% morphology
count% motility% spermia% perm antibody Teratozoospermia%
factor%
Manna N et al 17 32.85 6.57 46$ 10.95 5.11
Sultana et al 13 10.9 18.18 6.36 6.36
sefrioui et al 18 40
Thonneau 9* 17 39# 10
P et al 16 21@
Yeboah E et al19 69.4 30.8
Present study 10.48 17.75 8.07 4.03 59.67
* secretory &excretory azoospermia; $low fructose content; # normal semen; @ oligoteratoasthenospermia

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