|Year : 2014 | Volume
| Issue : 1 | Page : 7-11
The profile of infertility in a teaching Hospital in North West Nigeria
Abubakar A Panti1, Yusuf T Sununu2
1 Department of Obstetrics and Gynecology, Usmanu Danfodiyo University Teaching Hospital, Sokoto State, Nigeria
2 Department of Obstetrics and Gynecology, Federal Medical Center, Birnin, Kebbi, Nigeria
|Date of Web Publication||20-Mar-2014|
Abubakar A Panti
Department of Obstetrics and Gynecology, PMB - 2370, Usmanu Danfodiyo University Teaching Hospital, Sokoto State
Background: Infertility is a global health problem and a socially destabilizing condition for couples carrying several stigmas and a cause of marital disharmony. We determined the prevalence, causes, and clinical pattern of infertility at Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto. Materials and Methods: This was a prospective study conducted at the Gynecological Department of UDUTH Sokoto between 1 st January, 2011 and 31 st July, 2011. All the patients that presented with infertility within the study period were recruited into the study. Relevant demographic, clinical, and laboratory/radiological data were documented using a structured questionnaire. The patients had their case folders tagged and followed up to 31 st December 2011 (6 months). Data was analyzed using SPSS version 11. Results: A total of 1,264 new gynecological cases were seen during the study period, and 198 infertile patients were evaluated. The prevalence of infertility was 15.7%. Primary infertility constituted 32.8%, while secondary infertility was 67.2%. Previous history of evidence of genital infection including lower abdominal pain (78.8%) and vaginal discharge (76.6%) were common. Female gender-related causes of infertility accounted for 42.9%; male causes accounted for 19.7%. Both partners contributed to infertility in 16.7%, while no cause was found in 20.7% of patients. Conclusion: The study shows a dominance of secondary infertility with probable genital tract infection being a major contributor. Early presentation and prompt treatments of genital tract infections may reduce the prevalence of infertility in the study population.
Keywords: Causes, infertility, profile
|How to cite this article:|
Panti AA, Sununu YT. The profile of infertility in a teaching Hospital in North West Nigeria. Sahel Med J 2014;17:7-11
| Introduction|| |
Infertility is defined as the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.  Infertility is primary if the couples are unable to get pregnant, while secondary infertility is the inability to get pregnant after an earlier pregnancy. Worldwide, infertility is generally quoted as occurring in 8-12% of couples.  However, the incidence varies from one region of the world to the other, being highest in the so-called infertility belt of Africa that includes Nigeria.  In contrast to an average prevalence rate of 10-15% in the developed countries,  the prevalence of infertility has been notably highly variable in sub-Saharan Africa ranging from 20-46%. This has been attributed to high rate of sexually transmitted diseases, complications of unsafe abortions, and puerperal pelvic infections.  About 30% of infertility is due to female problems, 30% to male problems, and 30% to combined male/female problems, while in 10%, there is no recognizable cause. 
The causes of infertility has been categorized into four main causes; male infertility when it is principally due to poor semen parameters, female infertility when infertility is due to factors such as occlusions of fallopian tubes, uterine or endometrial abnormalities, abnormal cervix and anovulation in female partner. 
Institutional-based incidence of infertility reported in some parts of Nigeria are 4.0%,  15.4%,  and 48.1%  from Ilorin (North central), Abakaliki (South east), and Oshogbo (South west), respectively. There is scarcity of data on infertility in the North Western Nigeria. The objective of the study was to determine the prevalence, clinical pattern, and causes of infertility in a tertiary health institution in northwest Nigeria.
| Materials and Methods|| |
This was a prospective study conducted at the gynecological clinic of Usmanu Danfodiyo University Teaching Hospital Sokoto between 1 st January, 2011 and 31 st July, 2011. For the purpose of this study, all patients who complained of inability to conceive for a period of at least 12 months of trying to achieve a pregnancy were recruited. A total of 1,264 new gynecological cases were seen during the period of study. The study sample included 232 couples attending infertility clinic. All the patient had their history taken and physical examination conducted. For the purpose of this study, all patients are to have seminal fluids analysis, abdominal ultrasound, and hysterosalpingography done as appropriate. After obtaining consent, the patients had their case notes tagged with a sticker 'infertility study' and followed up to 31 st December, 2011. The relevant clinical findings and results of investigations were documented using a structured questionnaire, which was interviewer-administered. The interview was conducted in the native language (Hausa) or English.
Only female patients with full investigations and male partners that did seminal fluid analysis were included in the study analysis. Ethical approval for the study was given, and patients gave full consent. The data were extracted from the questionnaire and analyzed using SPSS version 11.
| Results|| |
The total number of the new gynecological cases during the period of study was 1,264. Of these, 232 were recruited with a diagnosis of infertility, but only 198 were analyzed. Thirty-four patients were lost to follow-up.
The prevalence of infertility was 15.7%. Of these, 65 (32.8%) had primary and 133 (67.2%) had secondary infertility. The demographic and clinical parameters are shown on [Table 1]. The age range was 17-47 years with a mean of 28.9 ± 6.5 years. The mean parity was 0.95 ± 1.3. The mean duration of infertility was 7.47 ± 1.6 years with maximum duration of 30.5 years. Most of the patients presented late for evaluation with 53.0% presenting after 5 years. [Table 2] shows relevant symptoms in the patients. Chronic pelvic pain, previous vaginal discharge, and dyspareunia were the commonest features being present in 156 (78.8%), 152 (76.6%), and 132 (66.7%) patients, respectively. Only 51 (25%) patients had previous investigations for infertility. Of the 83 (41.9%) patients who were treated previously for infertility, 54 (65.1%) had used traditional medication. Home was the place of last delivery of 60 (62.5%) parous patients. Female causes accounted for 85 (42.9%), while male causes accounted for 39 (19.7%). Causes of infertility was present in both partners in 33 (16.7%) cases, and there was no cause found in either partner in 41 (20.7%).
[Table 3] shows the physical signs demonstrated in the patient. Galactorrhea, vaginal discharge, and cervical motion tenderness were commonest signs present in 98 (49.5%). 97 (49.0%), and 63 (3.1.85%) patients, respectively. Abnormal body mass index was demonstrated in 73 (36.9%) patients with 37 (18.7%) being overweight. Uterine enlargement was demonstrated in 22 (1 1.1%) patients. Only 19 (9.6%) female patients had the male pattern of hair distributions. [Table 4] shows the investigation result of the female partners. The commonest findings on abdomino-pelvic ultrasound were uterine fibroid and polycystic ovaries in 17 (8.6%) and 17 (8.6%) patients, respectively. Significant fluid collection in the pouch of Douglass was seen in 12 (6.1%) patients. Hematometra was demonstrated in 1 patient. The most frequent finding on hysterosalpingography was tubal blockage seen in 53 (28.9%) patients with 31 (17.1%) having bilateral tubal blockage. Asherman's syndrome was seen in 14 (7.5%) patients. Uterine anomaly was seen in 2 (1.1%) patients.
[Table 5] shows the results of seminal fluid analysis. Abnormality of semen volume was seen in 36 (23.8%) patients. Mild oligospermia was seen in 23 (15.2%) patients, and 13 (8.6%) patient had severe oligospermia. Azoospermia was seen in 17 (12.6%) patients. Disorder of sperm motility was seen in 36 (26.6%) patient with 1 (0.7%) patient having no motile spermatozoa.
| Discussion|| |
The African traditional society places a high premium on the size of the family, be it nuclear or extended. In this society, a woman's childlessness may be viewed as a punishment for a social misdemeanor or attributed to other factors including witchcraft and the disaffection of one's ancestors. Childlessness is a dreaded outcome of any marriage in the traditional African society and often leads to polygamy and broken marriages but rarely child adoption.  The prevalence of infertility of 15.7% among the gynecological patients in our study is surprisingly low, though this agrees with previous studies, ,,,, but lower than 48.1% reported in Oshogbo  and higher than 4.0% reported from Ilorin.  The low prevalence in the current study may be attributed to the cultural beliefs stated above, which make infertile couple seek help from native doctors and prayer groups rather than orthodox Medicare. This was observed in this study where 65.1% had previously used traditional medications.
The predominance of secondary infertility (67.2%) in the current report agrees with previous studies in Africa ,,, but contrasts the finding in most Western societies where primary infertility accounts for 61-71% of cases, while secondary infertility is seen in 29-33% of patients. , The high prevalence of infertility in sub-Saharan Africa has been attributed to the sequelae of poorly managed pelvic inflammatory disease, resulting in utero-tubal damage and or pelvic adhesions.  This was supported by the high frequency of clinical evidence of pelvic infection including chronic pelvic pain (78.8%), previous vaginal discharge (76.6%), dyspareunia, and abortions observed in this study.
Late presentation of infertility was common in this study with 53.0% of patients presenting after 5 years of infertility. The delay in seeking assistance may be due to poor knowledge of infertility, unavailable and/or inaccessibility of appropriate services, prior unsuccessful medical intervention, and previous visits to traditional healers.  Previous consultations of traditional healers and previous medical evaluations were noted in this study. Poor coital exposure was noted in 63 (31.8%) patients. This may be due to polygamous nature of some partners, decreased libido of either partner, or partners living apart. A coital frequency of thrice or more per week is required to effectively cover the periovulatory period without resorting to timing of coitus.  In a polygamous set up, which is common in the setting of current report, it may not be practicable to meet up with the required coital frequency. This may be responsible for infertility in most patients in the study population. The commonest features were chronic pelvic pain, previous vaginal discharge, and dyspareunia suggesting previous pelvic inflammatory disease, sexually transmitted infections, post-abortal or post-partum genital tract infections.  Features of on-going infection manifested by lower abdominal tenderness, vaginal discharge, cervical motion tenderness, and adnexal tenderness were also noted.
This study shows a greater contribution of female factor (42.9%) as opposed to male factor, which is 19.7% and agrees with previous studies in Nigeria. , Tubal blockage was found in 53 (28.9%) patients who had HSG. This finding was similar in 48 (25.3%) patients who had tubal blockage confirmed by HSG.  The most predisposing factor to tubal infertility is pelvic inflammatory disease. With each successive episodes of PID, the risk of infertility doubles. Despite its typically mild presentation, chlamydial PID results in a threefold increase in infertility compared to gonococcal PID. 
Forty-seven (23.7%) male partners declined to submit themselves to semen analysis. This may be due to their perception of female partner as the only one responsible for infertility, fear of stigmatization or previous conception with other partner(s) in polygamous settings or both. Abnormality of semen volume was seen in 36 (23.8%) patients. This was higher than the 7.3% reported in Enugu Eastern Nigeria.  The abnormality might be due to lack of abstinence prior to collection of samples, improper collection, retrograde ejaculation, or partial blockage of vas deferens.  Oligospermia, azoospermia, and asthenospermia were the semen parameter abnormalities observed in the study. 26.6% of the males that had seminal analysis had low motility, which was similar to previous studies. ,
In conclusion, the study shows that the prevalence of infertility was 15.7% in the study population. Infertility was dominated by secondary infertility, late presentation, and evidence of pelvic infection. We recommend prevention of pelvic infection through safe sex, provision of safe abortion care, and essential obstetric services as measures of reducing the incidence of infertility in the study population.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]