|Year : 2021 | Volume
| Issue : 2 | Page : 70-74
The etiology of infertility in the western region of Libya: An investigation of medical records
Abdallah Eldib1, Osama A Tashani2
1 MENA Research Group; School of Clinical and Applied Sciences, Leeds Beckett University, Leeds, United Kingdom; Faculty of Medicine, Al-Zintan University, Al-Zintan, Libya
2 MENA Research Group; School of Clinical and Applied Sciences, Leeds Beckett University, Leeds, United Kingdom
|Date of Submission||29-Mar-2021|
|Date of Acceptance||13-Jun-2021|
|Date of Web Publication||23-Jul-2021|
Dr. Abdallah Eldib
School of Clinical and Applied Sciences, Leeds Beckett University, City Campus, Leeds LS1 3HE
Source of Support: None, Conflict of Interest: None
Aim: The aim of this study is to investigate the etiology of infertility in couples seeking medical help from the Infertility Clinics and gynecological departments in hospitals in Western Libya. Patients and Methods: Data were collected directly from patients' medical records. However, additional data were collected through interviews. Results: The total number of couples recruited was 135. Men (mean ± standard deviation of age = 41.7 ± 7.0 years) were significantly older than women (35.2 ± 6.5 years) (P = 0.001). Women were more likely to marry younger than men (mean difference = 6.5 years, 95% confidence interval [CI] =5.1–7.8 years) and the duration of all participant's marriages before the interviews was 9.0 ± 5.0 years. The causes of fertility were as follows: 33 (24.4%) (95% CI 17.16–31.64) cases were due to a female factor, 92 (68.1%) (95% CI = 60.24–75.96) cases were due to a male factor with 6 (4.4%) (95% CI 0.94–7.86) cases of combined male and female factor and 4 (3%) (95% CI = 0.12–5.88) cases without explained cause. Out of all patients, only 13 (4.8%) (95% CI = 2.25–7.35) were cases of secondary infertility and 257 (95.2%) (95% CI = 92.65–97.75) were cases of primary infertility. In females, the most common causes of infertility were ovulation disorders with 40 (23.4%) (95% CI = 17.05%–29.75%), polycystic ovary syndrome with 23 (13.5%) (95% CI = 8.38%–18.62%), irregular or no menstruation with 19 (11.1%) (95% CI = 6.39%–15.81%). The most frequent findings in males were 76 cases (31.0%) (95% CI = 25.21%–36.79%) asthenospermia, 75 cases (30.6%) (95% CI = 24.83%–36.37%) showing teratospermia and 56 (22.9%) (95% CI = 17.64%–28.16%) with oligospermia. Conclusions: Infertility due to male factor in Libya (approximately 70%), was very high compared to data from other regions of the world. Infertility due to the female factor is comparable to other regions of the world. The main cause for female factor infertility was ovulation disorders. Further research of infertility in other parts of the Middle Eastern and North African region is needed. This research must combine epidemiological, medical, and social investigations to find the main causes of infertility in the region.
Keywords: Etiology, female factor and male factor, infertility, Middle Eastern and North African region
|How to cite this article:|
Eldib A, Tashani OA. The etiology of infertility in the western region of Libya: An investigation of medical records. Libyan J Med Sci 2021;5:70-4
|How to cite this URL:|
Eldib A, Tashani OA. The etiology of infertility in the western region of Libya: An investigation of medical records. Libyan J Med Sci [serial online] 2021 [cited 2023 Mar 30];5:70-4. Available from: https://www.ljmsonline.com/text.asp?2021/5/2/70/322202
| Introduction|| |
Infertility is a global reproductive health issue, which has social and psychological consequences. Research to understand the causes of infertility is still poor in many developing countries including in the Middle Eastern and North African region (MENA). In a recent systematic review on the prevalence of infertility in the MENA region, eight cross-sectional studies of a total of 35,274 women revealed that 16% of participants were classed as infertile according to the clinical definition of infertility which is defined as “a disease of the reproductive system (characterized) by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.”
Our systematic review extracted data from the Department of Health report on the infertility of 35,494 women from four countries in the MENA region. This data suggested a higher infertility rate of 36.5% according to the demographic definition of infertility. This definition is widely used in international organization surveys, and defines infertility as “an inability to become pregnant with a live birth, within 5 years of exposure based upon a consistent union status, lack of contraceptive use, nonlactating and maintaining a desire for a child.”
The studies and surveys in this systematic review used different definitions of infertility and when analyzed using a comprehensive meta-analysis software it was clear that they are highly heterogeneous with I2 = 99%. What was evident from all of these studies is that there was no reporting of the causes of infertility in the MENA region.
Causes of infertility can be attributed to male factor, female factor, both male and female factors or unexplained. More specifically, the male factor can be low sperm count (Oligospermia), poor sperm motility (Asthenospermia), abnormal sperm morphology (Teratospermia), and other abnormalities. Causes of infertility in females include: Ovulation disorders, polycystic ovary syndrome (PCOS), multiple ovarian cysts, hypothalamic dysfunction, premature ovarian insufficiency, damage to Fallopian tube More Detailss (tubal infertility), endometriosis, uterine or cervical causes, irregular or no menstrual periods and more. It has also been reported that genetic factors could be one of the causes of infertility.
In addition to these pathological and biological factors, there can be some psychological and social causes of infertility which is related to certain behavior affecting couples trying to have children. Among the psychological factors, literature suggested that depression and emotional distress can be risk factors for not having children. The role of depression in the pathogenesis of infertility has been also reported. A delay in having children for new couples in religious and conservative communities such as in the middle east can be a stressful experience, especially for women. Various psychological responses appear in couples who are facing infertility problems, including low self-esteem, anger, sadness, jealousy toward other couples who already have children, anxiety, and depression.
Due to the heterogeneity in the criteria used to define infertility, (1 vs. 2 vs. 5 years of trying, and whether infertility is defined as being affecting women, men, or couples) comparing the results presented here with other studies in the region and globally is challenging. Global primary rates of infertility in 1990 was 2.0% and secondary infertility was 10.2%, in 2010 primary infertility was 1.9%, and secondary infertility was 10.5%.
There is a need to study the causes of infertility in The MENA region to inform practice to improve interventions to help couples to have children. Therefore, the aim of this study is to identify the etiology of infertility in couples seeking medical help in the Western region of Libya. The primary outcome of this study is to estimate whether infertility was due to male or female factors and what is the likely medical reason for this infertility.
| Patients and Methods|| |
This is a retrospective study of patient's records and medical notes which contains the history of the condition, laboratory tests, doctors' notes, treatment, etc., However, invited couples were also interviewed to fill gaps in the medical records, specifically obtaining more demographic data.
Out of over 20 hospitals and infertility clinics in Western Libya, 10 were selected by applying simple random sampling using random generator software. Random sampling of patients is practically difficult on site because patients have no patient numbers or codes. Instead, days and times of visiting clinics to meet patients were randomly assigned using a random number generator. Selected patients' records were obtained in the presence of patients. In total, 270 infertile patients' (135 couples) records were collected.
Data collection and analysis
Data were transcribed into predesigned data collection sheets. The data included: age, area, occupation, education, smoking, alcohol and drugs consumption, family income, marriage history including date of marriage, age when married, duration of the marriage and previous marriage, pregnancy, children, miscarriage, infertility, cause of infertility, factor of infertility, medications.
Continuous data such as age and duration of marriage were expressed as mean and standard deviation (SD). Other demographic data and causes were expressed as proportions and different cross-tabulations were produced to describe the data. Inferential statistics were applied when appropriate using Chi-square to compare between different proportions.
Ethical approval was granted by Leeds Beckett University local ethics committee and permission to access patients' details from clinics in Libya was issued by the local Libyan Health Authority. Participants consented to their records being investigated after a participant information sheet was given, explaining the study, its aims and how procedures would be delivered. The medical history of participants and other relevant data were stored anonymously in password-protected software for future analysis.
| Results|| |
Medical notes of, and interviews with, 135 married couples from Western Libya were investigated. The region of the study was divided into four areas according to the following percentages: City of Tripoli 37.8%, south area of Tripoli 33.3%, east area of Tripoli 17%, and the west area of Tripoli 11.9% [Table 1]. Men (mean ± SD of age = 41.7 ± 7.0 years) were significantly older than women (35.2 ± 6.5 years) (t = −7.9, P = 0.001). Women were more likely to marry at a younger age than men (mean difference = 6.5 years, 95% confidence interval [CI] =5.1–7.8 years) and all of the participants' duration of marriage before the interviews was 9.0 ± 5.0 years [Table 2].
|Table 1: Distribution of infertile couples according to residence areas of west region of Libya|
Click here to view
|Table 2: Demographic and behavioral characteristics of infertile participants from western Libya (n=135 couples)|
Click here to view
More men had obtained a university degree (61%) while only 45% of women had a degree (z = 2.6338 m, P = 0.009). There were also more women with no qualifications (10%) compared to none of the men who said they have no qualifications (z = 3.7697, P = 0002). Almost three-quarters of men were employed, (74.1%) compared to a fifth of all women (19.3) (z = 9.0242, P < 0.00001). Women were more likely than men to work as teachers and 45.9% of them declared that the best description for them is a housewife. About 18.5% of men are self-employed, and <1% of women do this job [Table 2].
Out of all patients, only 13 (4.8%) (95% CI 2.25–7.35) were cases of secondary infertility and 257 (95.2%) (95% CI 92.65–97.75) were cases of primary infertility [Table 3].
The medical records, which are compiled by the examining clinical team, revealed that the causes of fertility were as follows: 33 (24.4%) (17.16–31.64) cases were due to a female factor, 92 (68.1%) (95% CI 60.24–75.96) cases were due to a male factor with 6 (4.4%) (95% CI 0.94–7.86) cases of combined male and female factor and 4 (3%) (95% CI 0.12–5.88) cases without an explained cause [Table 4].
In terms of female factor the most common causes of infertility were ovulation disorders 40 (23.4%) (95% CI 17.05–29.75), PCOS 23 (13.5%) (95% CI 8.38–18.62), irregular or no menstruation 19 (11.1%) (95% CI 6.39%–15.81%). Cases where no female causes of infertility were recorded were 89 (52.0%) (95% Cl 44.51–59.49). Concerning male factor, the most frequent findings were 76 cases (31.0%) (95% CI 25.21–36.79) showing poor sperm motility (asthenospermia), 75 cases (30.6%) (95% CI 24.83–36.37) showing abnormal sperm morphology (teratospermia), and 56 (22.9%) (95% CI 17.64–28.16) with low sperm count (oligospermia). Cases where no male causes of infertility were recorded were 38 (15.5) (95% Cl 10.97–20.03). These three conditions existed simultaneously in most cases [Table 5].
|Table 5: Most common causes of infertility in 135 couples in western Libya as per their medical records|
Click here to view
| Discussion|| |
This is the first report of causes of infertility in Libya. Infertility due to male factors was very high in the Western region of Libya compared to data from other regions of the world. Male factor infertility in this study was 68.1% while female factor infertility was 24.4% and a combination of male and female factors was only 4.4%. In contrast, a study in Nigeria found that the male factor was only 28.6%. Another study in Nigeria reported a higher female factor (at 51.8%) than a male factor (at 26.8%) and both male and female factors were contributory in 21.4% of cases. Another study in China showed that, female factor were 60.0%, male factor were 11.3% and a combination of male and female factors was 6.2% while unexplained reasons were 22.5%. A study in Moshi, Northern Tanzania showed, that female-only factor infertility was identified in 65.9% of the couples, male-only factor contributed to 6.8% of cases, both male and female factors were found in 15.2% of cases and unexplained infertility was found in 12.1% of cases. In another study in Turkey, the male factor infertility proportion was 45.6%. The high male factor infertility we found may be due to socio-cultural reasons as men, in Libya, are more unlikely to keep a marriage if the cause was due to a female factor.
All causes of male factor infertility were related to semen count and abnormalities. For the male factor, the most frequent findings were 31% showing poor sperm motility (asthenospermia), 30.6% showing abnormal sperm morphology (teratospermia), and 22.9% with low sperm count (oligospermia). 15.5% was nonmale factor infertility. These three conditions existed simultaneously in most cases. This finding is similar to a study in Australia, Oligospermia 35% asthenospermia, and teratospermia 30%.
Some of the causes of male infertility can be treated. However, oligospermia, asthenospermia, and teratozoospermia which account for 84.5% of male infertility in western Libya are categorized as untreatable subfertility. There is some promising treatment for these conditions, but it is not available in Libya. For example, in a case report Ebner et al. reported that a healthy live birth was possible after treating a male diagnosed with asthenospermia using Theophylline.
Infertility due to the female factor is comparable to other regions of the world. The main causes for female factor infertility were ovulation disorders. Ovulation disorders were 29.6%, PCOS were 17.0% and irregular or no menstruation were 14.1%. This was slightly different from rates reported in other parts of the MENA region. For example, the ovulatory disorders rate was 39.7% in Iran and it was 35.3% in northern Tanzania. The prevalence of PCOS in the middle east was 6.1% in 1990, 16.0% in 2003, and 12.0% in 2006.
The age of women in this study at 35.2 ± 6.5 years was significantly less than a study in Iran, where the age of women was 40.3 (9.3) years, but comparable to the age of women in Nigeria which was 33.8 ± 5.2. Women in the study in Saudi Arabia were 33.38 ± 5.39 years, and in Lahore, Pakistan, 31.75 ± 5.47 years, while that of men was 35.78 ± 5.27 years. Women were more likely to marry younger than men, (mean difference = 6.5 years, 95% CI = 5.1–7.8 years), in this study, 27.5 ± 6.5 years was the mean age of marriage, 24.2 ± 5.2 for women and 30.7 ± 6 for man [Table 2]. In a study in Iran, the age of marriage for women was 20.6 (4.49) years. Women in Libya were more likely to stay in marriage even if the couple had no children (the duration of marriage was 9.0 ± 5.0 years in this study compared to Saudi Arabia 5.4 ±4.2, and Pakistan 5.50 ± 3.51 years).
Among infertile couples attending clinics in this study, primary infertility was as high as 95.2% and secondary infertility was 4.8%. This is slightly higher than estimates in Saudi Arabia which showed that primary infertility was 80.5% and secondary infertility was 19.5%. In contrast to studies in Iran and Pakistan, our estimate of primary infertility was higher than that reported in the province of Hamadan in which the prevalence of primary and secondary infertility was 69.5% and 30.5% respectively and in Lahore, Pakistan, in which 62.7% of infertile couples had primary infertility and 37.3% had secondary infertility. Lower estimates were reported in Africa as a study in Moshi, Northern Tanzania showed that primary infertility was 37.1% and secondary infertility was 62.9%.
Strengths and limitations
This is the first study of its kind in Libya and was conducted despite the recent civil war that engulfed the country. The sample size was, however, focused on a specific geographic area and therefore does not represent the whole of the country. The participants were all infertile couples and the data presented here is not adequate to estimate the prevalence of infertility. This is also a retrospective study and data were mainly collected by clinicians in the clinics and hospitals surveyed.
| Conclusions|| |
Infertility due to male factor, in Western Libya, at approximately 70% was very high compared to data from other regions of the world. This is probably due to social reasons as men in Libya, are more unlikely to keep a marriage if the cause was due to a female factor. Infertility due to the female factor is comparable to other regions of the world. The main cause for female factor infertility was ovulation disorders. Further research of infertility in other parts of the MENA region is needed. This research must combine epidemiological, medical, and social investigations to find the main causes of infertility in the region.
The authors would like to acknowledge the Libyan Ministry of Health for their help and support in data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Eldib A, Tashani O. Infertility in the Middle East and North Africa Region: A systematic review with meta-Analysis of prevalence surveys. Libyan J Med Sci 2018;2:37-44. [Full text]
Zegers-Hochschild F, Adamson GD, de Mouzon J, Ishihara O, Mansour R, Nygren K, et al.
International committee for monitoring assisted reproductive technology (ICMART) and the World Health Organization (WHO) revised glossary of ART terminology, 2009. Fertil Steril 2009;92:1520-4.
Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA. National, regional, and global trends in infertility prevalence since 1990: A systematic analysis of 277 health surveys. PLoS Med 2012;9:e1001356.
Matzuk MM, Lamb DJ. Genetic dissection of mammalian fertility pathways. Nat Cell Biol 2002;4 (Suppl):s41-9.
Tabong PT, Adongo PB. Understanding the social meaning of infertility and childbearing: A qualitative study of the perception of childbearing and childlessness in Northern Ghana. PLoS One 2013;8:e54429.
Boyce KE, Purser DA, Shields TJ. Experimental studies to investigate merging behaviour in a staircase. Fire and Materials 2012;36:383-98.
Al-Homaidan HT. Depression among women with primary infertility attending an infertility clinic in Riyadh, Kingdom of Saudi Arabia: Rate, severity, and contributing factors. Int J Health Sci (Qassim) 2011;5:108-15.
Al-Asadi JN, Hussein ZB. Depression among infertile women in Basrah, Iraq: Prevalence and risk factors. J Chin Med Assoc 2015;78:673-7.
Wiweko B, Anggraheni U, Elvira SD, Lubis HP. Distribution of stress level among infertility patients. Middle East Fertil Soc J 2017;22:145-8.
Adegbola O, Akindele MO. The pattern and challenges of infertility management in Lagos, Nigeria. Afr Health Sci 2013;13:1126-9.
Olatunji AO, Sule-Odu AO. The pattern of infertility cases at a university hospital. West Afr J Med 2003;22:205-7.
Li Y, Zhang X, Shi M, Guo S, Wang L. Resilience acts as a moderator in the relationship between infertility-related stress and fertility quality of life among women with infertility: A cross-sectional study. Health Qual Life Outcomes 2019;17:38.
Larsen U, Masenga G, Mlay J. Infertility in a community and clinic-based sample of couples in Moshi, Northern Tanzania. East Afr Med J 2006;83:10-7.
Öztekin Ü, Caniklioğlu M, Sarı S, Selmi V, Gürel A, Işıkay L. Evaluation of male infertility prevalence with clinical outcomes in middle Anatolian region. Cureus 2019;11:e5122.
Barak S, Baker H. Clinical management of male infertility. In: Endotext. South Dartmouth (MA): MDText.com, Inc.; 2016.
Ebner T, Shebl O, Mayer RB, Moser M, Costamoling W, Oppelt P. Healthy live birth using theophylline in a case of retrograde ejaculation and absolute asthenozoospermia. Fertil Steril 2014;101:340-3.
Kazemijaliseh H, Ramezani Tehrani F, Behboudi-Gandevani S, Hosseinpanah F, Khalili D, Azizi F. The Prevalence and Causes of Primary Infertility in Iran: A Population-Based Study. Glob J Health Sci 2015;7:226-32.
Ding T, Hardiman PJ, Petersen I, Wang FF, Qu F, Baio G. The prevalence of polycystic ovary syndrome in reproductive-aged women of different ethnicity: A systematic review and meta-analysis. Oncotarget 2017;8:96351-8.
Al-Turki HA. Prevalence of primary and secondary infertility from tertiary center in eastern Saudi Arabia. Middle East Fertil Soc J 2015;20:237-40.
Butt A, Chohan MA. Comparative efficacy of density gradient and swim-up methods of semen preparation in intrauterine insemination cycles. J Pak Med Assoc 2016;66:932-7.
Masoumi SZ, Parsa P, Darvish N, Mokhtari S, Yavangi M, Roshanaei G. An epidemiologic survey on the causes of infertility in patients referred to infertility center in Fatemieh Hospital in Hamadan. Iran J Reprod Med 2015;13:513-6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]