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RHO archives : Topics : Infertility

Annotated Bibliography

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Investigation of the causes of male infertility

Bonde, J. et al. Relation between semen quality and fertility: a population-based study of 430 first-pregnancy planners. Lancet 352:1172-1177 (1998).
This study followed 430 Danish couples for six months while they were trying to conceive their first child. After adjusting for sexual activity and female factors associated with low fertility, the probability of conception was associated with the proportion of sperm of normal morphology and with sperm concentration. Neither semen volume nor sperm motility affected the likelihood of conception. While WHO guidelines set a lower limit of 20x106/mL for normal sperm concentration, the likelihood of conception in this study continued to increase until a level of 40x106/mL was reached. The authors conclude that some men with sperm counts in WHO's normal range may in fact be subfertile.

Chia, S.E. et al. Study of the effects of occupation and industry on sperm quality. Annals of the Academy of Medicine of Singapore 23(5):645-649 (1994).
This study investigated the effects of occupational exposure on the fertility of 614 men undergoing an initial screening for infertility in Singapore in 1991-1992. The men were divided into case and control groups, based on their semen characteristics. Plant and machine operators had nearly twice the risk of oligospermia as other occupational groups (adjusted for age, smoking, medical history and testicular size), perhaps because of exposures to excessive heat. Workers in the transport and communication industry had 1.8 times the risk of abnormal sperm motility, but their excess risk could not be attributed to excessive noise, heat, or solvents in the workplace.

Gopalkrishnan, K. et al. Semen characteristics of asymptomatic males affected by Trichmonas vaginalis. Journal of in Vitro Fertilization and Embryo Transfer 7(3):165-167 (1990).
To examine the impact of the sexually transmitted parasite, Trichomonas, on male fertility, this study collected semen samples from 1,131 men whose wives were diagnosed with bilateral tubal occlusion and from 52 fertile men. Testing found that 4.42 percent of the samples were infected with Trichomonas, and they showed significant differences from the semen of fertile men, including decreased motility, decreased viability, a lower percentage of morphologically normal forms, increased seminal viscosity, a higher percentage of particulate debris, and more sperm showing hypoosmotic swelling. After a single course of treatment for the parasite, about half of the infected men showed a significant improvement in their semen characteristics. The authors conclude that Trichomonas, which is generally asymptomatic in men, may be responsible for some male infertility.

Ibeh, I.N. et al. Dietary exposure to aflatoxin in human male infertility in Benin City, Nigeria. International Journal of Fertility 39(4):208-214 (1994).
This article investigates the effect of aflatoxins (fungal metabolites that commonly contaminate staple foods in tropical countries) on the sperm of men and rats. The first study compared the semen of 50 men attending infertility clinics in Nigeria and 50 fertile men from the same community. Forty percent of the infertile men and 8 percent of the fertile men had aflatoxins in their semen. When aflatoxins were present, the sperm exhibited lower motility, lower viability, and more abnormalities. A second study examined the semen of rats who were fed a diet high in aflatoxins for 14 days. Compared to rats on a normal diet, these rats had semen with a lower sperm count, lower motility, lower viability, and a greater proportion of abnormal sperm. The authors conclude that different diets or individual differences in the ability to metabolize and excrete aflatoxin could account for the results.

Ikechebelu JI, Adinma JIB, Orie EF, Ikegwuonu SO. High prevalence of male infertility in southeastern Nigeria. Journal of Obstetrics and Gynaecology. 2003;23(6):657659.
In this article, the authors analyzed the records of 314 couples seeking evaluation for infertility at two gynecology clinics in Southeastern Nigeria. Initially, 431 couples were evaluated. Of those, 117 were excluded from the analysis because they failed to complete the investigation of the causes of infertility; in 82 cases (19.0%), the husband did not agree to semen analysis. In the remaining 314 couples, the investigations determined that the cause of infertility in 133 couples (42.4%) was male factor alone. Eighty-one couples (25.8%) had female factor infertility and 65 (20.7%) couples had a combination of male and female factors. Unexplained infertility was found in 35 (11.1%) of couples. For men, oligozoospermia (71; 35.9%) and low motility (64; 32.3%) were the most common factors associated with infertility. Azoospermia was found in 34 (17.2%), and multiple factors were found in the remaining 29 men (14.6%). In addition, the semen analysis of 213 men (67.8%) tested positive on bacterial cultures. For women, the main factors causing infertility were tubal occlusion (77; 49.0%) and ovulatory problems (58; 37.0%). The authors recommend that health providers should be aware of the large contribution of male factor infertility and should encourage men to participate in infertility investigations with their wives.
The authors also suggest providing education for youth on the long-term risks, including infertility, associated with unprotected sex, unsafe abortion, and untreated reproductive tract infections and sexually transmitted diseases.

Irvine, D.S. Epidemiology and aetiology of male infertility. Human Reproduction 13 (Suppl. 1):33-44 (1998).
This article reviews what is known about the prevalence, etiology, diagnosis, and treatment of male infertility. The author concludes that, although male infertility is a common problem, little is known about its causes. This has hampered meaningful diagnosis and effective treatment of male infertility. The author criticizes the WHO diagnostic classification system for being largely descriptive and for not incorporating recent scientific advances, for example, in genetics.

Klonoff-Cohen, al. Effects of female and male smoking on success rates of IVF and gamete intra-Fallopian transfer. Human Reproduction 16(7):1382-1390 (July 2001).
Results from this prospective study suggest that both male and female smoking can have a negative impact on success rates of two treatments for infertility-IVF and GIFT. Detailed smoking histories were obtained from couples seeking infertility treatments with either IVF or GIFT. Men and women who ever smoked in their lifetime were compared to men and women who never smoked. The mean years of smoking for female smokers was 3.77 years (range 1 to 26 years), and for male smokers was 4.2 years (range 1 to 31). Various outcomes were examined, including the pregnancy rates and successful live birth rates. A multi-variate analysis was used to adjust for age, race, education level, alcohol and drug use, parity, type of treatment, and number of procedures attempted. This analysis showed that both couples who smoked (either one partner or both smoked) and women who smoked had a higher risk of not successfully conceiving and a higher risk of having a miscarriage. Risks increased if either the couple or woman smoked for more than 5 years at any point in their lifetime.

Krause, W. et al. Male infertility and genital chlamydial infection: victim or perpetrator. Andrologia 35:209-216 (2003).
This article reviews the literature to assess the evidence for and against the role of Chlamydia trachomatis in male factor infertility. The review found that even though there is evidence that C. trachomatis does infect certain male glands, there appears to be no conclusive association between the infection and male infertility. The most critical issue involving C. trachomatis infection, which is highly asymptomatic in men, is the increased risk of infection of the female partner. In females, C. trachomatis infection can have harmful consequences leading to infertility.

Kuku, S.F. and Osegbe, D.N. Oligo/azoospermia in Nigeria. Archives of Andrology 22:233-238 (1989).
This article reviews data from many different sources on the etiology of male infertility in Nigeria and tries to resolve their contradictions. The authors conclude that infection plays a greater role in male infertility in Nigeria than in the developed world. They also report a relatively high incidence of infertility due to vascular injuries suffered during hernia repairs, as well as an increasing impact from sickle-cell disease. While the lack of facilities and expense of testing has limited the investigation of hormonal abnormalities, evidence suggests that these may play an important role and should be part of male infertility management. The authors review the appropriate management for each of these problems.

Petrelli, G. Mantovani, A. Environmental risk factors and male fertility and reproduction. Contraception 65:297-300 (2002).
This review article explores the association between exposure to pesticides and other environmental toxins and reproductive risks. Previous research has focused on the direct impact of pesticide exposure on male germ cells. Additional research, however, indicates that some pesticides and other compounds may impact male fertility through less obvious channels, particularly disrupting the endocrine hormones. This disruption could affect reproductive development in young male workers, and could decrease fertility in adult workers. Effects of exposure to such chemicals may produce a delay in "time to pregnancy" or an increase in the incidence of spontaneous abortions among female partners of pesticide workers. The authors caution that more research is necessary and that results from epidemiological studies should be interpreted carefully due to the difficulties in examining pesticide exposure and male fertility.

Thomas, J.O. and Jamal, A. Primary testicular causes of infertility. Tropical and Geographical Medicine 47(5):203-205 (1995).
This study compares a series of 81 testicular biopsies in Saudi Arabia with published series from Nigeria, Canada, the United Kingdom, and the United States. The biopsies were conducted between 1984-1992 as part of routine infertility work-ups. Dramatic differences in the rate of hypospermatogenesis (ranging from a low of 4 percent in Saudi Arabia to a high of 48 percent in London) may be due to differences in climate, clothing, the incidence of malaria, and/or environmental pollution. The high rate of Sertoli-cell-only syndrome in Saudi Arabia (27 percent compared with rates of 8 to 15 percent elsewhere) may be due to the tradition of consanguineous marriages.

Thonneau, P. et al. Occupational heat exposure and male fertility: a review. Human Reproduction 13(8):2122-2125 (1998).
This article reviews evidence that high scrotal temperatures reduce both sperm quantity and quality in fertile men. The authors conclude that male fertility is reduced by occupations that expose men to radiant heat, for example, from ovens and welding equipment, and also by occupations that require men to sit for long periods, such as driving a taxi.

Yeboah, E.D. et al. Etiological factors of male infertility in Africa. International Journal of Fertility 37(5):300-307 (1992).
A series of 846 Ghanaian and Nigerian men who received an infertility work-up between 1973 and 1986 were the subjects of this study. After excluding men with normal sperm counts, 595 remained, of whom 31 percent were azoospermic and 69 percent oligospermic. The most common pathology was hypospermatogenesis (12%). There was also a high incidence of orchitis, epididymitis, fibrosis, schistosomal testes, and other inflammatory lesions of the testis compared with developed countries. The authors conclude that the prevention and treatment of infections in men are important for the reduction of male infertility.

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Effect of smoking, alcohol, and caffeine consumption on fertility

Augood, C. et al. Smoking and female infertility: a systematic review and meta-analysis. Human Reproduction 3(6):1532-1539 (1998).
This article reviews the methodology and results of 24 studies of smoking and female infertility published between 1968 and 1997. A meta-analysis of 12 case-control and cohort studies found that women who smoked were 60 percent more likely to be infertile than non-smokers. Other studies excluded from the meta-analysis also supported a link between smoking and infertility. The authors discuss potential sources of bias in the study designs and possible confounding factors arising from life-style difference between smokers and non-smokers. They conclude that the evidence for a link between smoking and female infertility is compelling because the effects of smoking are consistent across different study designs, sample sizes, and types of outcomes.

Bolumar, F. et al. Smoking reduces fecundity: a European multicenter study on infertility and subfecundity. American Journal of Epidemiology 143(6):578-587 (1996).
Over 8,000 couples in five European countries provided retrospective information on the waiting times to their first and most recent pregnancies and on their smoking habits in this 1991-93 study. Half were selected from population registries, and half were pregnant women recruited during prenatal care visits. After adjusting for education, age, coffee consumption, recent use of oral contraceptives, and frequency of intercourse, the results showed no significant association between fecundity and male smoking. However, women who smoked more than 10 cigarettes a day were 1.6-1.7 times more likely than nonsmokers to wait more than 9.5 months before conceiving. The authors recommend that women having difficulty conceiving should stop smoking or smoke less. They also review possible mechanisms to explain the link between smoking and fecundity.

Bolumar, F. et al. Caffeine intake and delayed conception: a European multicenter study on infertility and subfecundity. American Journal of Epidemiology 145(4):324-334 (1997).
Over 3,100 couples in five European countries provided retrospective information on the waiting times to their first and their most recent pregnancies and their consumption of coffee, tea, and cola drinks in this 1991-93 study. After adjusting for confounding factors (age, parity, smoking, alcohol consumption, frequency of intercourse, educational level, working status, use of oral contraceptives, and country), the study found that women who drank more than 500 mg of caffeine per day, which is roughly equal to 4 cups of coffee, were 1.45 times more likely than other women to wait longer than 9.5 months before conceiving. The effect of high caffeine consumption was stronger for smokers (OR = 1.56) than non-smokers (OR = 1.38). The authors conclude that high levels of caffeine intake may delay conception.

Bolumar, F. et al. Body mass index and delayed conception: a European multicenter study on infertility and subfecundity. American Journal of Epidemiology 151(11):1072-1079 (2000).
Over 2,500 women from five European countries who had planned pregnancies provided retrospective information on the waiting time to their most recent pregnancy, their weight before pregnancy, and their consumption of cigarettes and caffeinated drinks during this 1992 study. After adjusting for confounding factors (age, parity, number of miscarriages, smoking, alcohol and caffeine consumption, cycle length and regularity, frequency of intercourse, use of oral contraceptives, job, medical history, and country), the study found that, among women who smoked, obese women were 11.54 times more likely than others to wait longer than 9.5 months before conceiving while lean women were 1.7 times more likely to have delayed conception. There was no association between delayed conception, obesity, or leanness among nonsmokers. The authors conclude that women having difficulty conceiving should initially focus on smoking cessation, which they may find easier in the short term than weight reduction.

Chia, S.E. et al. Factors associated with male infertility: a case-control study of 218 infertile and 240 fertile men. British Journal of Obstetrics and Gynaecology 107(1):55-61 (2000).
This case-control study recruited 218 men from couples being screened for infertility at a Singapore hospital; there was no known cause for their infertility. The controls consisted of 240 men whose pregnant wives were attending the antenatal clinic at the same hospital. Three significant risk factors for infertility were identified: sperm density, sperm viability, and smoking. Smoking posed the greatest risk, with an adjusted odds ration of 2.96.

Curtis, K.M. et al. Effects of cigarette smoking, caffeine consumption, and alcohol intake on fecundability. American Journal of Epidemiology 146(1):32-41 (1997).
This retrospective cohort study of 1,277 Ontario farm couples analyzed caffeine and alcohol intake, cigarette smoking, and time to conception for 2607 planned pregnancies. The analysis controlled for a variety of potential confounding factors, including age, education, income, diseases, drugs, work, contraceptive method, weight, and recent pregnancy. The likelihood of conceiving during a given cycle decreased by 12 percent when the woman smoked more than 10 cigarettes a day, by 16 percent when the woman smoked more than 20 cigarettes daily, by 11 percent when the husband smoked, and by 28 percent if both husband and wife smoked. Fecundability was not depressed for ex-smokers. There was no association between fecundability and caffeine consumption, but data was collected on current rather than past caffeine consumption and may be inaccurate. While there was no overall association between alcohol consumption and fecundability, the likelihood of conceiving was slightly lower for women who drank more than two glasses of wine a week and for men who drank more than 10 glasses of beer or six glasses of liquor per week.

Grodstein, F. et al. Infertility in women and moderate alcohol use. American Journal of Public Health 84(9):1429-1432 (1994).
This case-control study interviewed 1,050 women with diagnosed infertility and 3,833 women who had recently given birth. After adjusting for women's age, smoking, caffeine use, number of sexual partners, IUD use, body mass index, and exercise, the analysis found that moderate to heavy alcohol consumption increased the risk of two diagnostic categories of infertility: ovulatory factor and endometriosis. For ovulatory factor infertility, the odds ratios were 1.3 for moderate drinkers (defined as women consuming less than 100 g of alcohol per week) and 1.6 for heavier drinkers (women consuming more than 100 g of alcohol per week), when compared with women who did not drink. For infertility due to endometriosis, the odds ratios were 1.6 for moderate drinkers and 1.5 for heavy drinkers.

Hakim, R. et al. Alcohol and caffeine consumption and decreased fertility. Fertility and Sterility 70(4):632-637 (1998).
This prospective study gathered urine specimens and information about menstrual cycles and sexual activity on a daily basis from 124 women working in the semiconductor industry. Information on smoking, alcohol, and caffeine intake was gathered monthly. Smoking had the greatest impact on fertility: smokers had a conception rate of 6.3 percent compared with 16.8 percent for non-smokers. Among non-smokers, the consumption of even small amounts of alcohol significantly reduced fertility: the conception rate fell from 24.5 percent for non-drinkers, to 17.3 percent for women consuming 1 drink a week, to 11.9 percent for 2-7 drinks, and to 8.3 percent for 8 drinks or more per week. Caffeine consumption reduced fertility only among women who also drank alcohol.

Jensen, T. et al. Does moderate alcohol consumption affect fertility? Follow up study among couples planning first pregnancy. British Medical Journal 317(7157):505-510 (1998). Available at: 7157/505).
This prospective study followed 430 Danish couples age 20-35 for six months while they were trying to conceive for the first time. It measured alcohol intake more accurately than previous retrospective studies by asking couples to report their alcohol intake each month around the time of ovulation. After adjusting for potential confounding factors (smoking, diseases in female reproductive organs, oral contraceptive use, women's body mass, sperm concentration, and duration of menstrual cycle), the results show that alcohol consumption by women reduced the likelihood of conception. The more the women drank, the greater the impact. However, even moderate alcohol consumption reduced fecundability. Compared with non-drinkers, the odds ratio for conceiving was 0.61 for women consuming 1-5 drinks each week, 0.55 for women consuming 6-10 drinks each week, and 0.34 for women consuming more than 10 drinks each week. Alcohol consumption by men did not affect fecundability.

Kunzle, R. et al. Semen quality of male smokers and nonsmokers in infertile couples. Fertility and Sterility 79(2):287-291 (2003).
Previous studies of the effects of smoking on semen quality have produced inconsistent results, due most likely to varying definitions of "smokers" and small sample sizes. This study sought to analyze a large group of smokers and nonsmokers using a strict threshold of one cigarette a day or more to define a "smoker." Analysis of semen samples from 655 smokers and 1,131 nonsmokers found that men who smoked had a statistically significant lower total sperm count and increased abnormal sperm morphology than men who did not smoke. The authors suggest that men who have below average sperm quality should consider quitting smoking while trying to have children.

Parazzini, F. et al. Alcohol consumption is not related to fertility in Italian women. British Medical Journal 318:397 (1999). Available at:
This letter analyzes data previously collected as part of an Italian case-control study on risk factors for spontaneous abortion. Women in the control group, all of whom were interviewed after giving birth, were divided into a group of 135 who reported difficulty in conception and a group of 1,634 who reported no such difficulty. No relationship was found between alcohol consumption (whether less or more than two drinks a day) and difficulty conceiving.

Windham, G.C. et al. Cigarette smoking and effects on menstrual function. Obstetrics & Gynecology 93(1):59-65 (1999).
This prospective study of smoking and menstrual function collected daily urine samples, daily diaries of cigarette consumption and vaginal bleeding, and detailed interviews from 408 women. Menstrual cycles during which women smoked more than 20 cigarettes a day were almost four times as likely to be short (less than 25 days) as cycles during which no smoking occurred; this effect was due to shortening of the follicular phase among smokers. Moderate smokers (10 or more cigarettes daily) were almost three times as likely as nonsmokers to have cycles of irregular length and had almost twice the risk of anovulation. A long history of smoking also was associated with shorter cycles and possibly anovulation, but ex-smokers did not have cycles of irregular length. These menstrual changes may explain the negative impact of smoking on fertility.

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Timing intercourse to increase the likelihood of conception

Huang, F. et al. Timed intercourse after intrauterine insemination for treatment of infertility. Obstetrics & Gynecology and Reproductive Biology 80:257-261 (1998).
This prospective study examined intrauterine insemination among 201 infertile couples in Taiwan. All couples were treated with the same course of ovarian stimulation and intrauterine insemination (IUI). Half also were instructed to have intercourse within a 12-18 hour period following insemination. Timed intercourse significantly improved the pregnancy rate in couples with a lower number of motile sperm inseminated (<40x106) (27.7% versus 10.5%), but not in couples with a higher sperm number (25.7% versus 22.7%). The authors conclude that timed intercourse is a simple and inexpensive way to increase the efficacy of IUI among certain patients.

Simpson, J.L. Pregnancy and the timing of intercourse. New England Journal of Medicine 333(23):1563-1565 (1995).
This cohort study analyzed charts kept by sophisticated users of natural family planning to determine the length of the fertile period. Of the 524 pregnancies recorded in Chile, Columbia, Italy, and the U.S., 76.4 percent were conceived on the day of ovulation or the two days prior. However, a few were conceived more than 6 days prior to ovulation, and a few were conceived the day after ovulation. The article also reviews information on the timing of intercourse, the sex ratio among newborns, and chromosomal abnormalities in newborns. The author recommends that couples trying to become pregnant track the woman's menstrual cycles and time their intercourse to take place before ovulation.

Wilcox, A.J. et al. Timing of sexual intercourse in relation to ovulation. New England Journal of Medicine 333(23):1517-1521 (1995).
To investigate the number and timing of fertile days during the menstrual cycle, this prospective study followed 221 women who were trying to become pregnant. Urine specimens were collected daily to determine the date of ovulation, and the women kept daily records of sexual intercourse. During each of the 192 cycles that resulted in pregnancy, intercourse took place at least once during a six-day period including the day of ovulation and the five days preceding. The authors conclude that couples who want to conceive should have intercourse before ovulation, rather than waiting for ovulation to occur.

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Combating myths and misperceptions

Brady M. Preventing sexually transmitted infections and unintended pregnancy, and safeguarding fertility: triple protection needs of young women. Reproductive Health Matters. 2003;11(22):134-141.
In this article, the author argues for reframing messages of dual protection to include preserving fertility. A new message of “triple protection” against unintended pregnancy, STIs/HIV, and infertility would highlight the connection between STIs and infertility as well as the connection between unsafe abortion, unhygienic delivery practices, and infertility. The triple protection message also would help bridge the gap between family planning/reproductive health programs and STIs/HIV programs. The author calls for strategically building on the momentum of programs promoting dual protection and for increased research on young men and women’s knowledge about dual or triple protection, the risks and consequences of STIs, and infertility.

Dyer SJ, Abrahams N, Mokoena NE, van der Spuy ZM. ‘You are a man because you have children’: experiences, reproductive health knowledge and treatment-seeking behaviour among men suffering from couple infertility in South Africa. Human Reproduction. 2004;19(4):960-967.
Researchers conducted in-depth interviews to explore the reproductive health knowledge and treatment-seeking behavior around the issue of infertility of 27 men attending infertility clinics. The majority of the men lacked knowledge of the biology related to human reproduction, the causes of infertility, or the treatment options. Some men identified more medical factors related to infertility such as low sperm count, blocked tubes, or sexually transmitted diseases. Several men also mentioned concerns about the previous use of contraception; lifestyle factors such as drugs, diet, or stress; as well as punishment from God, angry ancestors, or witchcraft. In general, among this sample, awareness of male factor infertility was high. This could be due in part to the sample being comprised of men already seeking investigation into the causes of couple infertility. Men reported a range of effects—both positive and negative—that infertility has had on their marital relationships. A few men felt they had become better at coping with the issue as a couple and that they had increased empathy for infertility's emotional impact on their wife. Almost half of the men reported experiencing pressure and ridicule from family members and the majority reported stigma and ridicule from members of their community. The authors conclude that further exploration of men’s experience with infertility is necessary in order to increase their involvement in infertility management.

Okonofua FE, Coplan P, Collins S, et al. Impact of an intervention to improve treatment-seeking behavior and prevent sexually transmitted diseases among Nigerian youths. International Journal of Infectious Disease. 2003;7:61-73.
Authors conducted a randomized controlled trial in 12 schools in Nigeria to determine the impact of an intervention on STI prevalence and youth’s treatment-seeking behavior. The intervention consisted of community involvement, peer education, lectures, and in-school clubs for youth. In addition, STI treatment providers (including medical practitioners, patent medical dealers, and pharmacists) participated in the training. Authors analyzed data from 1,896 and 1,858 pre- and post-intervention surveys with youth aged 14 to 20 in intervention and control schools. Results showed statistically significant increases among the intervention group in youth’s knowledge of STIs, condom use, STI treatment-seeking behavior, and increase in partner notification (particularly among females notifying their partners if they had an STI).

Olukoya AA, Elias C. Perceptions of reproductive tract morbidity among Nigerian women and men. Reproductive Health Matters. 1996;7:56-63.
Authors conducted a qualitative study of men and women’s perceptions of reproductive tract infections and reproductive tract morbidity. Focus group discussions revealed, among other issues, that fertility was highly valued in the community and women had many fears around loss of fertility. Infertility was viewed as being caused by God or witchcraft, or by the use of contraceptives. In particular, women reported concerns about over use or improper use of hormonal contraceptives, including both pills and injectables. In addition, abortion was frequently cited as a cause of infertility. While some women realized that infections associated with unsafe abortions were the cause, several women thought that infertility was a punishment for having an abortion. Authors recommended that men and women would benefit from efforts to improve awareness of reproductive tract infections, comprehensive knowledge of contraceptives and their side effects, enhanced service delivery capacity, and interventions to encourage responsible sexuality.

Stanback J, Twum-Baah KA. Why do family planning providers restrict access to services? An examination in Ghana. International Family Planning Perspectives. 2001;27(1):37-41.
This article reports the findings from 97 interviews conducted in 1994 with family planning providers in Ghana. The interviews were designed to investigate why providers created barriers to access, and were conducted at 46 facilities that were identified, in an earlier study, as having barriers to clients’ access to family planning services. The sample of the 96 providers included 52 auxiliary nurses, 42 professional nurse-midwives, two extension workers, and one volunteer. Restrictions were grouped into four main categories: spousal consent, minimum age restrictions, maximum age restrictions, and minimum parity restrictions. Results of the interviews highlighted a lack of technical knowledge of the eligibility criteria for and side effects of modern contraceptive methods. Restrictions placed on family planning methods were frequently rationalized to protect women from infertility or other risks. Minimum age and parity requirements were often used to verify a woman’s fertility in order to protect providers from being blamed if the woman later proved infertile. Providers had misinformation about injectable contraceptives, in particular, and apparently believed that injectables could cause a slow return to fertility or permanent infertility. These same concerns were cited as reasons for restricting access to hormonal contraceptive pills and IUDs. The authors recommend that family planning standards and protocols are strengthened and based on evidence such as WHO’s Medical Eligibility Criteria for Contraceptive Use to contend with the issue of restrictive barriers to access to family planning.

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