Prevalence of infertility in women
The percentage of women of reproductive age (15-49 years) at risk of becoming pregnant (not pregnant, sexually active, not using contraception and not lactating) who report trying to become pregnant for two years or more.
This indicator is calculated as:
(Number of sexually active women age 15–49 at risk of becoming pregnant who report trying unsuccessfully to become pregnant for two or more years / total number of women of reproductive age at risk of becoming pregnant ) x 100
Responses to a survey question asking women of reproductive age who are at risk for pregnancy how long they have tried to get pregnant.
The question can be posed by an interviewer or asked in a written survey. The method of questioning will depend on the literacy level of the population of women surveyed.
It is useful if data can be disaggregated by women’s age group, by “ever been pregnant” and by “length of time trying for pregnancy”.
Also, some experts prefer the “five or more years” timeframe for assessing infertility.
Population-based surveys including a birth history if estimates of primary and secondary infertility are desired
This indicator provides a population-based estimate of infertility prevalence through the assessment of trying time to pregnancy (or “failure to conceive”). While clinical studies are the principal source of data on infertility causes and treatment, a population-based estimate, though not medically verifiable, can be used to assess the social burden of the condition and the potential demand for treatment services. The indicator can also be used as a measure of reproductive morbidity and a proxy measure of the long-term sequelae of gynecological infections.
The prevalence of infertility as a measure of reproductive morbidity is a useful marker of progress towards improved reproductive health, defined by the ICPD as “the capability to reproduce and the freedom to decide if, when and how often to do so.”
Infertility, or the inability to produce a live birth after adequate sexual exposure without contraception, can affect both the man and the woman. To date, there has not been widespread attention on infertility, except in isolated cases or on a small scale, due to limited resources, policies aimed at reducing population growth, and the expense of modern infertility treatment (Dhont, et. al, 2010). Current estimates of infertility in developing countries are primarily based on Demographic and Health Survey (DHS) birth history data and do not include the self reported time to pregnancy question. However, these estimates show that primary infertility, or childlessness, remains relatively rare, with rates between 1-10% in women aged 25-49. In contrast, the percentage of women experiencing secondary infertility, or an inability to produce a live birth after at least one previous birth, ranges from 9-38% (Rutstein and Shah, 2004). Prevalence is often highest in centrally located African countries, but estimated rates can vary from region to region even within the same country.
In many parts of the developing world, where having children constitutes the main purpose of marriage, infertility is considered a curse and a tragedy for the couple, entire family and community. There are several factors that can affect the prevalence of infertility including:
- Prevalence of sexually transmitted infections (STIs), e.g. gonorrhea;
- Incidence of postpartum and postabortion infections;
- Socio-cultural factors such as the practice of female genital cutting; and
- Age of the partners.
There is conclusive evidence that much of the infertility in Africa is attributable to infections that produce irreversible reproductive tract damage in men and women, suggesting a need for public health programs to reduce these causes, including STI control and education programs to raise awareness about the link between high-risk sexual behavior and infertility (Okonofua, 2003). Curative treatment of infertility is inaccessible for most couples in developing countries due to its very high cost and low success rate (Dhont, 2010). However, if a country-wide program implements a prevention strategy involving the effective control of STIs, appropriate postpartum care, and safe abortion techniques, this indicator may be one way of measuring the long-term impact of such initiatives.
In regions where infertility is high, there will be more demand for treatment services, both in the traditional and formal health sectors. Until effective fertility treatments become more affordable and accessible, health authorities can in the meantime determine the extent of the problem and invest in improving information, education and counseling on causes and treatments of infertility, which have proven to reduce the stigmatization and suffering of infertile clients (Dhont, 2010).
Information for this indicator comes from a single, self-reported question that is easy to calculate and interpret. It is assumed that information about risk of pregnancy (exposure to sexual intercourse and status of contraceptive use, pregnancy and lactation) is also collected. Use of this indicator avoids potential biases associated with the use of birth history intervals to calculate childlessness and infertility, including misclassification due to incomplete contraceptive and marital histories.
The indicator measures the extent of difficulty or failure to become pregnant, rather than inability to produce a live birth. As a consequence, the indicator may fail to capture infertile women who have achieved conception but experienced one or more spontaneous abortions. In addition, it should be noted that some women reporting a waiting time until pregnancy of two or more years may in fact become pregnant in the future without intervention.
This indicator does not differentiate between primary and secondary infertility. However, if birth histories are also collected in the survey, this distinction can be made. The differentiation can be important as often secondary infertility is more prevalent in a population and suggests poor access or quality of health care during the previous pregnancy, delivery, or postpartum period, and/or ineffective treatment of gynecological infections, including STIs.
A significant issue is that this indicator addresses only a woman’s failure to conceive. Nevertheless, this failure of conception is used as a measure of a couple’s infertility, which comprises inability to conceive by both the male and the female partner. The cause of the couple’s infertility could be female, male or both. Using this indicator, and therefore failing to address the male factor in infertility, may contribute to a further stigmatization of women (WHO, 2006).
Infertility in many parts of the world has damaging consequences for men’s and women’s health. Due to the high cultural premium placed on childbearing in many countries, infertility often poses serious social problems for couples (Okonofua, 2003). However, women are often more severely affected than men, even when the infertility is due to a male factor, often leading to divorce, financial difficulties, self-blame, social ostracisation and sometimes physical abuse of women (Okonofua, et. al, 2007).In certain areas where motherhood defines an individual woman’s social status, self-worth, and treatment in the community, the inability to produce offspring means a woman is not regarded as a proper woman. Consequently, there is now a growing body of scientific opinion that suggests that addressing infertility could be one way to empower women and improve their sexual and reproductive health (Okonofua, 2002).
Dhont, N., S. Luchters, W. Ombelet, J. Vyankandondera, A. Gasarabwe, J. van de Wijgert, and M. Temmerman. 2010. “Gender Differences and Factors Associated with Treatment-seeking Behavior for Infertility in Rwanda.” Human Reproduction 25 (8): 2024-2030.
Rutstein, S.O., Shah, I.H. 2004. Infecundity, Infertility, and Childlessness in Developing Countries. DHS Comparative Reports No. 9. Calverton, MD, USA: ORC Macro and the World Health Organization.
Okonofua, F.E. 2003. “New Reproductive Technologies and Infertility Treatment in Africa.” African Journal of Reproductive Health 7: 7-8.
“Reproductive Health Indicators: Guidelines for their generation, interpretation and analysis for global monitoring”. WHO, 2006.
Okonofua, F.E., D. Harris, A. Zerai, A. Odebiyi, and R.C. Snow. 1997. “The Social Meaning of Infertility in Southwest Nigeria.” Health Trans Rev 7: 205–220.
Okonofua, F.E. 2002. “What about us? Bringing infertility into reproductive health care.” Quality/Calidad/Qualite 13: 1–2.