Infertility: Causes in African Women and Men with Prevention Tips

By: Dr. Azuka Ezeike, MBBS, FWACS (Obstetrics and Gynaecology), FMCOG, MSc (Public Health). Medically reviewed by: Dr. Tii Ngwachi Munghieng, MD.

 

Happy looking African couple dressed in colourful tops

 

Understanding Infertility

Within nine months of marriage, the expectation in most African societies is that the married woman would give birth to a baby. When a couple fails to achieve a pregnancy after a few months of marriage, they are subjected to societal pressure and even stigma. The travails of an infertile couple in African society are beyond words. 

The World Health Organization (WHO) defines infertility as a disease of the male or female reproductive system characterised by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse.

 The fact is that the cause of infertility can either be due to the male partner, the female or both. In some cases, it may be unexplained.

Although infertility affects both men and women, the women however bear the brunt in many localities.  This is a result of misconceptions (falsehoods) about the possible causes. It results in consequences like intimate partner violence, social stigma, divorce, career and mental health challenges among others issues.

This misunderstanding is fuelled by ignorance of the causes. This article aims to get rid of the misconceptions by providing accurate information on the causes of infertility in women and men.

 

Why is Fertility Important to Discuss?

Discussing fertility is important as infertility can limit a person’s fundamental right to decide how many children to have and when to have them. 

Also, there are many misconceptions about infertility, including the belief that it is always the woman’s fault. This misconception often causes delays in seeking proper treatment, as male partners may refuse to undergo evaluation.

Additionally, the high cost of fertility treatments and the complex role that initial access to unqualified practitioners play in causing delay in access to proper medical care, further highlight the need for broad public awareness and education on infertility. [1]

 

What Are the Types of infertility?

These include:

• Primary: When a person has never achieved a pregnancy despite having unprotected sex for at least a year (or six months if 35 years or older).
• Secondary: This is when a person has achieved pregnancy once, but has been unable to do so thereafter
• Unexplained: When following fertility testing, a cause has not been found for why a person or couple has not achieved pregnancy. 

 

Who is Affected by Infertility in Africa?

Infertility affects one in six people in their lifetime, this accounts for about 17.5% of the world's adult population. Data from the WHO showed that from 1990-2021, the lifetime prevalence of infertility was 17.8% in high-income countries and 16.5% in low- and middle-income countries. This shows that infertility is a global threat,  

The data also showed that the prevalence of infertility in the WHO Africa sub-regions was 13%. The highest prevalence was 23.4% in the Western Pacific with the lowest prevalence of 10.8% in the eastern Mediterranean region. 

In the four WHO Africa regions shown, nearly 1 in 8 people (13%) have been affected by infertility in their lifetime. Source (p.13).

 

Though the prevalence is lower in Africa than in some other regions, people with infertility in Africa bear a lot of financial burden due to a lack of insurance coverage for fertility treatment in most countries.

A report that reviewed the results of multiple studies done across Africa showed that 54.01% of primary and secondary infertility cases in Africa were due to female factors and 22.26% to male factors.[2] Factors in both the male and family partners accounted for 21.36% of the infertility cases, while 10.4% were unexplained. Primary and secondary infertility accounted for 49.91% and 49.79% of cases respectively.

 

Risk Factors for Infertility

It is usual to conclude that infertility may be a consequence of an individual's past life. This is one of the reasons for the stigma associated with the condition in Africa. 

In a percentage of cases, it is unexplained and sometimes cannot be traced to any risk factor. In other instances, it could be linked to some risk factors. [6] 

The factors that increase the risk of infertility include: 

• Age (more significant for women than men)

• Unsafe sexual practices resulting in increased risk of sexually transmitted infections 

• Unsafe abortions (i.e., deliberate and non-professional ending of a pregnancy) resulting in an increased risk of infections of the female reproductive organs

• Hormone-linked disorders that cause diverse health issues that may affect fertility

• Family history of fertility problems

• Substance abuse: excessive alcohol consumption, smoking and illicit drug use

• Obesity

• Recurrent miscarriage

• Complications from past childbirth

• Environmental  and  workplace exposure to toxins like radioactive substances and lead

• Occupations that affect the function of the testis; e.g., long distance driving. This results in a prolonged increase in the temperature of the scrotal sac, affecting sperm production by the testes.

 

What Causes Infertility?

Fertility requires a functional reproductive tract, namely the uterus (womb), ovaries and fallopian tubes in women and the testes in men. The sperm must pass through the cervix (mouth of the womb) and swim up to the fallopian tube. The egg must pass into the fallopian tube where it meets with the sperm for fertilization. The fertilised egg must pass down to the womb for implantation (i.e. attaching to, invading and growing within the inner lining of the womb). .

Any problem with these organs can impair these processes leading to infertility. In addition, the ovaries and testes are under the influence of hormones from the brain and other glands like the thyroid gland. Any dysfunction in these organs can also cause infertility. 

In about 1 in 4 couples, the cause of infertility may not be detected with routine tests. This is known as unexplained infertility.

 

 Causes of infertility in women

Female infertility could be due to: [3. 4]

• Problems with egg production (Ovulation problems)

• Problems with the fallopian tube

• Problems with the womb

• Issues from the pelvis/others

I. Ovulation problems

Ovulation problems result from the inability of the ovary to produce eggs regularly.

This can be due to several factors:

• Polycystic ovarian syndrome: This is a disease that is associated with increased production of male sex hormones by the ovaries. This results in reduced egg production by the ovary.

• Ovarian ageing: As a woman ages, the number of eggs in the ovaries reduces, thus ovulation becomes infrequent. This usually becomes evident from around the age of 35.

• Damage to the ovaries due to medical treatment like surgery on the ovary, chemotherapy or radiotherapy for cancer treatment. 

Ovulation may also be affected by abnormality of hormones from the brain or thyroid gland. 

This can be due to conditions like:

• Hyperprolactinaemia(high prolactin level)

• Hyper and hypothyroidism(abnormal thyroid hormone level)

• Hypopituitarism (low luteinising (LH) and follicle-stimulating hormone (FSH) levels. The pituitary gland, an organ in the brain, produces these hormones.

II. Fallopian tube problems

The fallopian tube is a tiny tube that connects the womb to the ovary and pelvic cavity. It provides a passage for the egg and sperm. It is the place where the egg and sperm meet for fertilisation to occur. If it is blocked, this process is inhibited.

Fallopian tube blockage can result from factors like: 

• Pelvic inflammatory disease (or redness, swelling and pain involving the female reproductive organs in the pelvis) from sexually transmitted infections

• Infection from unsafe abortion

• Adhesion(scar) formation from damage due to previous surgeries 

• Adhesions resulting from endometriosis.

III. Problems with the womb

The womb is the place of implantation (attachment) of the fertilised egg and houses the pregnancy. Any problem with the womb may prevent implantation.

These include:

• Adhesion (scar) formation in the lining of the womb. This is known as uterine synechiae

• Fibroid and polyps: Fibroids are not always associated with infertility. However, they may lead to infertility if they: [3]
  • Block the fallopian tubes
  • Significantly distort the shape of the womb cavity
  • Block the cervix. 

• Abnormal womb: Some women are born with poorly developed wombs or abnormally shaped wombs and cervix.

IV. Other causes

• Endometriosis is a disease that affects women of childbearing age. It is caused by the implantation of the lining of the womb (endometrium) outside the original location. The presence of this tissue on organs like the ovary and fallopian tube can damage these organs leading to abnormal function. This leads to blockage of the tubes and problems with ovulation. 

In addition, the disease could cause adhesions (scar formation) that displace the pelvic organs from their original location. Its association with pain during sex also affects fertility.

• Immune-related disorders like Lupus are also associated with fertility problems. In these diseases, the body’s immune system attacks normal body tissues. This leads to a lot of inflammation (redness, swelling, pain and heat feeling) that may cause infertility.

• Partial or complete closure of the cervix and vagina. This manifests as cervical stenosis (i.e., narrowing and shortening) and vaginal gynaetresia. These may be inborn or could result from previous surgeries or in some cases from the use of corrosive herbal medications in the vagina.  These herbal medications are sometimes applied by women as a treatment for infertility. 

 

Causes of infertility in men

 The testis is the sperm-producing organ in men. Abnormalities in the number, shape and movement of the sperm are associated with infertility.

Infertility in males could be due to factors leading to: [5] 

• Reduced sperm production (pre-testicular and testicular)

• Defective sperm release (post-testicular)

I. Reduced sperm production

These can be to:

• Factors outside the testes (pre-testicular)

• Problems within the testes (testicular)

Pre-testicular

The causes include;

• Low levels of hormone (FSH and LH) production by the brain

• Other hormonal problems like thyroid hormone abnormalities

• Chronic illnesses like kidney problems, diabetes and liver problems

• Obesity

• Lifestyle factors like heavy alcohol use, tobacco and marijuana use

Testicular 

This is due to diseases of the testes like:

• Orchitis (inflammation of the testis)

• Trauma (injury) or torsion(twisting) of the testis

• Undescended testis; some males are born with the testis inside the pelvic cavity. If this fails to descend into the scrotum early enough it can lead to abnormal function

• Genetic disorders resulting in small and poorly functional testis and low male hormone(testosterone) levels, e.g.,  Klinefelter syndrome

• Varicocoele: enlargement of the veins in the scrotum leading to reduced function of the testis

• Lifestyle factors like long-distance driving and prolonged use of nylon underwear. These increase the temperature in the scrotum and lead to reduced sperm production by the testis

• Drugs. e.g. chemotherapy for the treatment of cancer

II. Defective sperm release

Post-testicular

In this case, the testis is functioning well but some factors prevent the release of produced sperm. 

These include:

• Blockage of the vas deferens, seminal vesicle, ejaculatory duct, and urethra. These are the structures that carry sperm from the testis to the opening of the penis. The blockages can result from sexually transmitted infection, trauma (injury) or they may be inborn.

• Diseases like cystic fibrosis: This is associated with the absence of the vas deferens.

• Ejaculatory disorders:  These include such conditions like premature ejaculation which may indirectly cause infertility due to early ejaculation outside the vagina, or through its psychological impact on the male partner due to apprehension, low self-esteem and loss of interest in sex. Also, retrograde ejaculation (or reversal of the flow of sperm into the bladder) may directly cause male infertility as a result of medication use, nerve problems or problems with the structure of the male reproductive organs. 

• Erectile dysfunction: problems with initiating and maintaining an erection.

 

Prevention of Infertility

Though infertility may be difficult to prevent in some cases, certain measures can help reduce the risk. These include;

Adopt a healthy lifestyle

• Maintain a balanced diet

• Exercise regularly

• Avoid excessive alcohol consumption and illicit drug use

• Minimise caffeine intake

• Manage stress effectively

• Maintain a healthy weight

Protect against sexually transmitted infections (STIs)

• Do not have unprotected sex at any time prior to planning to have a baby with your partner

• Avoid multiple sexual partners

• Seek early detection and treatment of Sexually Transmitted Infections (STIs).

Make informed fertility choices

• Avoid unsafe abortions

• Do not delay planning and having your baby unduly, particularly for the female partner

• Consider preserving sperm or eggs (freezing) if you must delay pregnancy, or if you are undergoing treatments that may damage the reproductive cells (the egg and sperm).

 

Conclusion

The journey of infertility can be challenging for any couple. In most cases, the cause can be linked to either the male, the female, or both partners. Sometimes, no specific cause is found. Individual and general public education about the possible causes leads to reduced misconceptions. This would help to reduce the stigma and societal pressure often associated with the condition and result in early presentation for diagnosis and treatment. Knowing that solutions exist can offer hope to those affected.

 

 

References

1. Nagy P, Groot W, Arsenijevic J, Dyer S, Mburu G, Kiarie J, Financial costs of assisted reproductive technology for patients in low- and middle-income countries: a systematic review, Human Reproduction Open, Volume 2023, Issue 2, 2023, hoad007. Doi: 10.1093/hropen/hoad007. Available from here..

2. Abebe MS, Afework M, Abaynew Y. Primary and secondary infertility in Africa: systematic review with meta-analysis. Fertility Research and Practice. 2020, 6(1):20. doi: 10.1186/s40738-020-00090-3 Available from here.

3. NIH - Eunice Kennedy Shriver National Institute of Child Health and Human Development. What are some possible causes of female infertility?  [Internet]. Last reviewed January 31, 2017. [Cited 2024 Sep 7]. Available from here. .  

4. Walker MH, Tobler KJ. Female infertility. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Last update: Dec 19, 2022. [Cited 2024 Sep 7]. Available from here.

5. Johns Hopkins Medicine. Male infertility [Internet, n.d.]. Cited 2024 Sep 7. Available from here.

 

 

Related:

Social Factors Shaping African Women’s Health

Unsafe abortion in Africa: Causes and Complications

10 Common Hormone-Linked Disorders in African Women

Common Gynaecological Cancers in African Women

Infertility in African Women: All You Need to Know

 

 

Published: December 16, 2024

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