Please note: This archive was last updated in 2005.

RHO archives : Topics : Infertility

Key Issues

This section provides summaries of infertility research topics relevant to low-resource settings. Click article references to read abstracts in the bibliography. More detailed discussions of specific key issues are included in the Annotated Bibliography.

Be sure to use the Glossary if you are unfamiliar with any of the terms on this page.

Geographic and ethnic variations in the prevalence of infertility

Researchers continue to refine the operational definition of infertility and develop new methodologies to measure its prevalence more accurately (Greenhall and Vessey 1990; Thonneau and Spira 1990). It is difficult to compare the results of past studies because they have employed such different sampling and measurement techniques. Recent analysis of a body of comparable data gathered by World Fertility Surveys and Demographic Health Surveys confirms, however, that variations in national, regional, and ethnic rates of infertility are both real and substantial (Ericksen and Brunette 1996; Larsen 2000) and may change over time (Larsen 1996; Larsen 2003). These variations in prevalence may shed light on the causes of infertility.

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Investigation of the causes of female infertility

A growing body of research has verified the importance of infection as a cause of female infertility worldwide and traced the link between STIs (including asymptomatic infections), postpartum infections, postabortion infections, PID, and tubal damage (Cates et al. 1985; Cates et al. 1994; Westrom 1994; WHO 1987; WHO 1995). In sub-Saharan Africa, tubal-factor infertility caused by the scarring, blockage, or damage of the fallopian tubes as a result of PID, is considered the primary cause of female infertility (Mayaud 2001). Chemical exposure poses an increasing danger as development proceeds, because women come into contact with a broader range of potentially toxic substances at work and in the home (Shahara et al. 1998; Greenlee et al. 2003). Research indicates that male exposure to certain chemical compounds could also play a mediating role in delaying the time to conception and in increased risk of spontaneous abortions (Petrelli and Mantovani 2002). Other researchers are examining factors of regional or local importance, including genital tuberculosis (Parikh et al. 1997), iodine deficiency (Longombe and Geelhoed 1997; Stewart 1991), local health care practices and marriage patterns (Inhorn and Buss 1994), and working hours (Tuntiseranee et al. 1998).

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Investigation of the causes of male infertility

Male infertility in developing countries has received far less attention than female infertility, and no overall patterns have been established as yet. Indeed, new research calls into question the basic WHO standards defining normal sperm concentration (Bonde et al. 1998). A growing body of research on sperm quantity and quality suggests the possible importance of infectious disease (Gopalkrishnan et al. 1990), occupational exposures (Chia et al. 1994; Thonneau et al. 1998), and diet (Ibeh et al. 1994) in developing countries. Nevertheless, country data indicate that in some areas male factors account for a large percentage of infertility (Ikechebelu et al. 2003). These data highlight the need for more thorough investigation of male partners in infertile couples. Conflicting evidence exists on the role of chlamydia infection in men. Control of this frequently asymptomatic infection, however, is critical to reduce the risk of transmission to female partners, where Chlamydia can cause serious sequelae like PID and subsequent infertility (Krause et al. 2003).

Men's exposure to certain pesticides that disrupt endocrine hormones is thought to have an impact on the couples' ability to conceive and carry the pregnancy to term (Petrelli and Mantovani 2002). Data from testicular biopsies show wide geographic variations, which may be caused by climate, clothing, endemic disease, or environmental pollution (Thomas and Jamal 1995).

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Effect of smoking, alcohol, and caffeine consumption on fertility

Women and men around the world expose themselves to nicotine, alcohol, caffeine, and other chemically active substances every time they smoke a cigarette, have a beer, or drink a cup of coffee. In recent years, well-controlled retrospective (Bolumar et al. 1996; Bolumar et al. 1997; Curtis et al. 1997), case-control (Grodstein et al. 1994), and prospective studies (Hakim et al. 1998; Jensen et al. 1998) have demonstrated that conception is delayed when women smoke or drink alcoholic beverages—even in moderate amounts—perhaps because smoking disturbs the menstrual cycle (Windham et al. 1999). While the evidence for drinking coffee and tea is less strong, data suggest that caffeine may interact with alcohol and smoking in women to further reduce fecundability. Men's consumption habits appear to have less impact on conception rates, but some studies suggest that smoking may pose a problem for men with borderline fertility (Chia et al. 1999), and that one cigarette or more per day can lower total sperm count and affect sperm morphology (Kunzle et al. 2003). Men and women should be aware that there is some evidence that suggests that smoking can reduce the chances of conceiving through the use of IVF and GIFT as well (Klonoff-Cohen et al. 2001). Researchers agree that women who are having difficulty conceiving should stop smoking and drinking alcoholic beverages or, at least, reduce their consumption as much as possible.

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Timing intercourse to increase the likelihood of conception

Recent studies have found that virtually all pregnancies are conceived in the six days leading up to ovulation, with conception most likely when intercourse takes place on the two days preceding ovulation and on the day of ovulation (Simpson 1995; Wilcox et al. 1995). This is of practical importance for couples using fertility awareness or natural family planning techniques to try to conceive: they should time their intercourse for the days preceding ovulation, rather than wait for ovulation to occur. (For information on how to identify fertile days, click on Also see the Natural Family Planning page in the Contraceptive Methods section.) Timing intercourse also may increase the effectiveness of some medical treatments for infertility, such as intrauterine insemination (Huang et al. 1998).

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Combating myths and misperceptions

Myths and misconceptions about the causes of infertility are common among both men and women. Infertility, in some communities, is attributed to witchcraft, punishment from God, or angry ancestors (Dyer et al. 2004; Olukoya and Elias 1996). Some misconceptions can lead to more serious health consequences. In some communities, infertility is attributed to the use of some methods of contraception (Okonofua 1996; Okonofua 1997; Olukoya and Elias 1996). Many women are reluctant to use modern contraceptives due to the fear of infertility. This, however, increases their risk of unintended pregnancy and the associated risks of postpartum infections or unsafe abortions. In addition, in some instances family planning providers hold these misconceptions as well. In Ghana, barriers to accessing contraceptive methods often were based on concerns that certain methods delay fertility or cause permanent infertility (Stanback et al. 2001).

Increased attention needs to be given to heightening awareness of the link between STIs and infertility. Recently, researchers have suggested incorporating infertility into efforts to promote dual protection methods (Brady 2003). By reframing dual protection as triple protection against unintended pregnancy, STIs/HIV, and infertility, researchers hope to draw attention to the often-neglected issue of infertility and to increase the links between reproductive health and STI prevention efforts (Brady 2003). In addition, health providers and program managers can help clients safeguard their health by providing education on the biological causes of infertility and the links between untreated or improperly treated STIs and infertility. For example, an intervention in Nigeria utilized peer educators, school-based health clubs, and provider training to increase youth knowledge of STIs and STI treatment-seeking behavior (Okonofua et al. 2003). Researchers hope that initiatives such as this will help safeguard young women’s fertility.

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Reducing risk of infertility through control of RTIs and STIs

By reducing the incidence and duration of STIs through primary and secondary prevention, STI-control programs can help reduce the complications and sequelae of STIs, such as PID, that can lead to infertility (Cates 1994; Chigumadzi 1998; WHO 1987). Primary prevention is typically addressed through education and behavior-change programs that promote safer sexual practices, which reduce exposure to STIs, and encourage men and women to seek early treatment if symptoms develop. Additional primary-prevention measures focus on vaccine development for STIs, although vaccines for bacterial STIs such as gonorrhea and chlamydia curently do not exist (Mayaud 2001).

Family planning programs can help reduce the incidence of infections that could lead to PID by promoting safer sexual practices and condom use, offering clients screening and treatment for STIs, providing referrals, and encouraging clients to seek STI services. In addition, family planning programs can prevent infection by providing safe and hygienic postabortion care (WHO 1987). By increasing the quality of care during delivery and avoiding unnecessary surgical procedures, obstetric and gynecologic providers can reduce the risk of introducing infection during delivery. Traditional birth attendants (TBAs) should also be trained in safe and hygienic delivery techniques (Mayaud 2001).

For more information on control and management of RTIs, see RHO's Reproductive Tract Infections section. For more information on linking fertility protection and STI prevention, see RHO's Special Focus: Dual Protection and HIV/AIDS.

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Managing infertile couples in developing countries

While women everywhere view infertility as an enormous burden, their response to the problem varies in different parts of the world. In India and Pakistan, infertile women seek help early and prefer the formal health care system over traditional practitioners. Due to the high cost of medical care and the lack of counseling, however, women frequently change doctors and/or cut treatments short (Bhatti 1999; Unisa 1999). In contrast, infertile women in Africa tend to delay care and consult traditional practitioners first. If they do visit a clinic or hospital, they often receive incomplete and haphazard care (Gerrits 1997; Sundby 1997). Barriers to seeking care often include the costs and transportation difficulties getting to health care centers, scarce health care services and limited supplies of medicines, and men's refusal to go through infertility assessments and testing. In the Gambia and Zimbabwe, couples' heavy reliance on traditional healers likely delays their seeking formal medical services (Sundby and Jacobus 2001). Similarly, research conducted in an urban slum in Bangladesh suggests that men and women perceive herbalists and traditional healers as their best treatment option for infertility (Papreen et al. 2000).

Developing effective services for infertile couples requires a two-pronged approach. First, education about the causes and treatment of infertility is important at the community level so that infertile couples do not automatically blame the woman, seek medical help promptly, and continue with prescribed treatments long enough to give them a chance (van Balen and Gerrits 2001; Okonofua et al. 1997). Second, health care providers should be trained to assess infertile couples thoroughly, establish firm diagnoses, and counsel couples about treatment options and the likelihood of pregnancy—all of which is possible even in low-resource settings. Infertility professionals agree on the need for histories and physical examinations of both partners and on the importance of following standard protocols. However, they continue to debate the ideal number of visits and necessary tests for an infertility work-up (Puttemans et al. 1995; Fiander 1990). Some researchers recommend that if a woman is diagnosed with bilateral tubal obstruction, and no assisted reproductive technologies are available, further time-consuming, costly testing (for both the staff and client) is not warranted (Stewart-Smythe and van Iddekinge 2003). WHO is developing new guidelines for infertility management as part of primary health care; they call for infertile couples to be screened at local clinics and referred to secondary and tertiary health facilities as needed (Rowe 1999; Usmani 1999). Researchers advocate for governments to invest in more quality-control and regulatory policies to help prevent exploitation of patients in low-resource settings (Van Zandvoort et al. 2001). By offering infertility education and services, family planning programs in developing countries can build a positive image for their program and for family planning, even as they meet a widespread health need (Singh 1996). Family planning programs also can help prevent infertility by reducing STI and PID risks among their clientele (CDC 2000).

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Evaluating treatment options for developing countries

In vitro fertilization and other assisted reproduction techniques have been successfully implemented in developing countries (Nicholson and Nicholson 1994; Vayena et al. 2002), although some researchers question whether they will ever be accessible at the local level by couples who need them due to cultural and economic constraints (Inhorn 2003). Cultural and religious values and beliefs, as well as the health care infrastructure and economic development, influence the level of services provided in any one country. In most cases, when assisted reproductive technologies are available, they are provided by the private sector, making infertiltiy services accessible only to the middle and upper classes (Vayena et al. 2002). In addition, the centers and physicians providing assisted reproductive technologies are often located in large cities, making it too time consuming and expensive for couples to access from more remote areas (Giwa-Osagie 2002).

Some critics question whether assisted reproductive technologies are an appropriate use of limited health care resources (Okonofua 1996; Sheth and Malpani 1997). It has been recommended that public health policy should invest in preventing the causes of infertility and leave the establishment of new assisted reproductive technologies to the private sector since it is unlikely to be cost-effective in the public sector (Okonofua 2003). Others argue on the other hand, that the social, emotional, physical, and economic consequences that infertile couples—and in particular, women—face justifies investing in treatment options in developing countries (Daar et al. 2002). Even in industrialized countries, however, cost-benefit studies indicate that couples should try conventional treatments before turning to assisted reproduction (Cheung 2000; Karande et al. 1999; Guzick et al. 1999; Goverde et al. 2000; Te Velde and Cohlen 1999). Other researchers are refining and evaluating less expensive and less technically demanding treatments that are a more practical alternative for low-resource settings. These include artificial insemination (Ombelet et al. 1995), laparoscopic surgical techniques (Anate and Akeredolu 1995; Kasia et al. 1997; Maruyama et al. 2000) and hormonal therapy for men (Sah 1998). Recent reviews, however, cast doubt on the effectiveness of all conventional therapies for the treatment of male factor infertility (Devroey et al. 1998; Kamischke et al. 1998). There also is some concern that drugs used to induce ovulation may increase the risk of ovarian cancer, but the evidence is unclear (Wakeley and Grendys 2000). Overall, cultural and religious values and beliefs, as well as the health care infrastructure and level of economic development, will continue to influence the level of services provided in any one country.

In an effort to make much needed assisted reproductive technologies to developing countries accessible and affordable, some researchers are looking to public-private partnerships. These partnerships can bring technical expertise, research, equipment, and supplies to low-resource settings. At the same time, public-private partnerships can offer services at lower costs that are more realistic in developing countries. In addition, public-private partnerships can help influence the establishment of standards, regulations, and policies to safeguard the health of couples undergoing treatment (Daar et al. 2002; Giwa-Osagie 2002).

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Reducing the psychological burden of infertility

Infertile couples around the world experience frustration, anger, guilt, sadness, grief, and loss—even clinical depression and anxiety—because of their inability to conceive (Aghwana et al. 1999; Tarlatzis et al. 1993). Social pressures and the stresses of medical treatment exacerbate this psychological burden, which women find especially heavy (Greil 1997; Whiteford and Gonzalez 1995). Health care providers can help couples cope with infertility by designing supportive services and offering psychological counseling (Kennedy et al. 1998; Woods et al. 1991). Interventions that provide educational information and teach new skills may produce more positive changes than interventions focused solely on counseling and expression of feelings (Boivin 2003). Two small studies suggest that psychological interventions might increase pregnancy rates among infertile couples, perhaps by reducing their distress or by helping them comply with treatment protocols (Domar et al. 2000; Tuschen-Caffier et al. 1999). However, other studies have found no effect (Boivin 2003). It is also important that providers help clients stop seeking treatment, accept their childlessness, and consider adoption after they have completed an appropriate course of treatment (Paulson and Sauer 1991). Boivin et al.'s (2001) guidelines, developed by a team of infertility professionals primarily from Europe, provide a useful framework for counseling infertile couples.

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