Infertility in African Women: All You Need to Know

 

By Victory Chukwuamaka Onyenekwe. B.Sc. Ed Physical and Health Education. Freelance Health Writer and Datelinehealth Africa volunteer. Medically reviewed by Dr. Azuka Ezeike, MBBS, FWACS  (Obstetrics and Gynaecology), FMCOG, MSc (Public Health).

 

African women dancing in a happy moment

 

Highlights

• Infertility is a condition of the female and male reproductive system, defined by the failure to get pregnant after 12 months or more of regular unprotected sex.

• The World Health Organization [WHO] reports that about 30% of women aged 25 – 49 years in Sub-Saharan Africa suffer from secondary infertility. 

• The most common cause of infertility in African women is blocked fallopian tubes caused by Pelvic Inflammatory Diseases (PID).

• Alcohol, smoking, abnormal menstrual cycles and chronic disease are risk factors for infertility.

• Treatment options for infertility include lifestyle modification, drugs, surgery, and assistive reproductive techniques.

• African women face various challenges in the treatment of infertility; such as poor social support, limited access to care, poor understanding of treatment options, stigma and high cost of care with little or no insurance coverage.

 

Introduction

There is a countdown for an African woman when she gets married. It is a countdown to her first pregnancy. In Africa where children are considered an integral part of any marriage, any sign of infertility in a woman is met with raised eyebrows and hushed murmurs. Infertile women in Africa face a lot of stigmas and are exposed to demeaning cultural practices. 

Quite a number of people in Africa do not understand why infertility occurs, especially in a woman. So, to understand the question ‘why’, we must first know what infertility is.

 

What is Infertility?

Infertility is a condition of the male and female reproductive system, defined by the inability to get pregnant after 12 months or more of regular unprotected sex.

There are mainly two types of infertility: 

• Primary Infertility: This refers to a situation where a woman has never been able to get pregnant.

• Secondary Infertility: This refers to when a woman has been able to get pregnant before, but finds it difficult to get pregnant again.

Infertility occurs in both men and women. In women, infertility can be caused by underlying factors such as blocked fallopian tubes, polycystic ovariansSyndrome [PCOS], Fibroids, Endometriosis, Sexually Transmitted Infections [STIs] etc.

 

How Common is Infertility in African Women

A literature review of infertility in sub-Saharan Africa, noted that the occurrence of infertility varies, ranging from 9% in Gambia, 21.2% in North-western Ethiopia, between 20 – 30% in Nigeria, 11.8% and 15.8% among men in Ghana. [1] This mostly excluded men from the discourse.

Demographic studies conducted by the World Health Organization [WHO] show that about 30% of women aged 25 – 49 in Sub-Saharan Africa suffer from Secondary infertility. [1]

Secondary infertility is much more common in Africa than primary infertility. [2] Another study conducted in Central Africa showed the occurrence of primary infertility in women to be from 3.1% to 6.9% and secondary infertility ranging from 18.9% to 26.5%. [3] 

Another study from Nigeria reported that the prevalence of primary infertility is 5% with secondary Infertility being 8%. [4].

 

Importance of Addressing Infertility in African women

In Africa, where procreation is considered as one of the main goals of marriage, women who struggle with infertility are treated quite harshly. Infertility can lead to emotional distress, anxiety, depression and generally affect the overall quality of a woman’s life.

In many African cultures, women who suffer infertility are often stigmatized, they face verbal abuse in the form of derogatory statements such as being called a ‘man’ or a ‘witch’ because it’s been assumed they have ‘eaten’ their unborn children. They also suffer physical abuse, discrimination and even divorce. It also has an economic impact as women may seek expensive treatments or remedies.

This article will examine infertility in African women and discuss harmful cultural practices and stereotypes that are associated with childlessness. It will also provide you with an understanding of the condition, its causes, risk factors, and treatment options.

 

Common Causes of Infertility in African Women

The most common cause of infertility in African woman can be grouped under the following categories:

Blocked fallopian tubes. 

This happens when one or both of the fallopian tubes are blocked, thereby preventing the sperm from reaching the egg. [5, 6] Blocked fallopian tubes are usually caused by Pelvic Inflammatory Diseases [PID]. Pelvic Inflammatory Disease is caused by sexually transmitted infections [STIs], pelvic tuberculosis, and complications from unsafe abortion and abdominal pelvic surgery.

Ovarian dysfunction 

These include: 

• Polycystic Ovarian Syndrome: This is a hormonal disorder that affects the ovaries.

• Primary Ovarian Insufficiency [POI], also known as premature menopause: This is a condition where the ovaries stop working normally before the age of 40 years.

Disorders of the Vagina, Cervix, and Womb

• Cervical stenosis: This is a narrowing or closure of the inner passage of the cervix due to abnormal development or previous surgery, cancer or radiation for cancer. It is a rare cause of infertility.

• Vaginal stenosis (Gynaetraesia): This commonly follows the cultural practice of insertion of corrosive substances into the vagina with the erroneous perception of tightening the vagina to enhance male sexual pleasure. 

• Uterine Fibroids: Non-cancerous growths in the womb [uterus]. Although uterine fibroid is not considered a common cause of infertility, it could be a contributory factor in cases where both tubes are blocked by fibroids or the womb cavity is distorted.  

• Malformed uterus: This is a developmental disorder of the uterus and a rare cause of infertility

Pelvic issue

• Endometriosis: Implantation of the lining of the womb outside the normal location i.e., on the ovaries, fallopian tubes etc. 

Others

• Other hormonal disorders such as thyroid (hyper or hypothyroidism), adrenal and pituitary gland disorders (prolactinemia or high prolactin level).

• Auto-Immune disorders: These are conditions where the immune system attacks healthy cells in the body. Examples of autoimmune disorders are lupus, and rheumatoid arthritis.

 

Risk factors of infertility in African women

The risk factors for infertility are things that increases the chance of being infertile. The following risk factors can lead to or increase the chances of an African woman being infertile:

• Advanced Age: Athough age is a risk factor for infertility in women, this is so established in men. Age impacts the quality and quantity of eggs in women and fertility in women usually declines from the early 30s and getting pregnant at age 45 while not impossible, may prove difficult.

• Smoking: Smoking has an adverse effect on fertility in women. It reduces the number of mature eggs that can be fertilized and make eggs that remain develop abnormally. It also decreases the level of the female hormones; estrogen and progesterone levels. Smoking also damages the fallopian tubes, and can cause the early onset of menopause.

• Alcohol: Consumption of alcohol may lead to menstrual irregularities, and disrupt the hormonal cycle in females. Women who abuse alcohol are known to have a variety of both menstrual and reproductive disorders. [7]

• Environmental factors: Exposure to industrial chemicals, harmful radiation, pesticides can result in endocrine and ovulation disturbance which can affect the fertility of a woman.

• Family history: Genetics can also be a risk factor for infertility in women. This could be through inherited genetic disorders like cystic fibrosis or being more predisposed to ovarian disorders like Polycystic Ovarian Syndrome, premature menopause, Endometriosis or Uterine Fibroids.

• Lifestyle: Lifestyle factors such as diet, exercise, substance abuse, medications, sexual indiscretion and multiple partners as well as exposure to psychological stress can result in infertility.

• Unsafe Abortion: Unsafe abortion increases the risk of Pelvic Inflammatory Disease (PID) and may be one of the causes of scars on the inner walls of the uterus, which could make it harder to get pregnant. This condition is called is known as Uterine synaechiae or the Asherman Syndrome. Other complications that can arise from unsafe abortion include perforation of the uterus and the weakening of the cervix.

• Weight abnormalities: Obesity or being overweight can increase infertility in both men and women. Women who are overweight are at high risk of experiencing menstrual dysfunctions and even difficulties with assisted reproduction. [8] It affects reproductive function by affecting the ovaries and the walls of the uterus [endometrium]. Underweight women who suffer from eating disorders such as anorexia nervosa are faced with menstrual dysfunction due to low energy. This dysfunction results in anovulation (no  menstrual period). [9]

• Abnormal menstrual cycle: There are various ways abnormal menstrual cycle can occur, these include: Amenorrhea (absence of menstruation), Oligomenorrhea [infrequent periods], Menorrhagia (heavy or prolonged bleeding). 

• Chronic diseases: African women battling with chronic diseases like diabetes, arthritis, hypertension, hyperthyroidism and hypothyroidism suffer a risk of infertility.

 

Pointers of Infertility in African Women

The main sign and symptom of infertility is the inability to get pregnant. However other signs and symptoms may arise from underlying conditions or factors that cause infertility. Some of these symptoms include:

• Menstrual cycle changes: Irregular periods, skipped periods, heavy or light bleeding, or no periods at all .
• Painful periods
• Hair loss
• Hirsutism [excessive hair growth]
• Skin changes
• Milky discharge from the breasts in the absence of breastfeeding
• Change in sex drive
• Painful sex

 

Diagnosis of Infertility in African Women

The diagnosis of infertility in an African women starts with a doctor taking a history from the woman and performing a physical examination. At the end of the examination, the doctor may order several tests to be conducted.

The tests may include the following:

• Blood tests: These may include
  • Complete blood count (CBC) and
  • Diverse ovarian hormonal assays like Luteinizing hormone (LH), Follicle stimulating hormone (FSH), Oestrogen, Progesterone, etc.,

These hormonal assays help to determine how well your ovaries function. They also help  to determine the ovarian reserve.

• Other hormonal assays include Thyroid function test: This test measures the level of thyroid hormones (T3, T4) in blood. It is not conducted routinely. It is only performed when thyroid disease is suspected as a cause of infertility.
   
• Hysteroscopy: This involves the use of a  thin lighted device called hysteroscope, that is passed through your cervix to check for any abnormality in in the womb cavity
   
• Hysterosalpingography (HSG): This test involves the insertion of a special tube tightly into your uterus and injection of a special dye into your womb. An X-ray of the pelvis is then taken while the dye is being injected to visualise the passage or otherwise of the dye through your fallopian tubes and into the pelvic cavity. An alternative live visualisation process is through a special X=ray screen called the fluoroscope. The HSG is an important test in the assessment of female infertility 
   
• Laparoscopy and dye test: This is done by making small incisions in the abdomen and inserting a small instrument with a camera at the end to view the pelvic organs of a woman. The laparoscopy is done to check whether the tubes are open and also to check the health status of other pelvic organs
   
• Ultrasound imaging: This involves the imaging of the pelvic organs using ultrahigh frequency sound with live visualization of the organs on a computer screen. Photographic images may also be recorded. 
   
• Semen analysis: No investigation of infertility is complete without a full semen analysis in the male partner of a couple under assessment for infertility. The semen analysis include:
  • Sperm volume
  • Sperm concentration
  • Sperm motility (movement)
  • Sperm morphology (shape)

• Other tests of male infertility like hormone assays, ultrasound scan, genetic testing, and biopsy of the testes may also be conducted as necessary. 

 

Treatment of infertility in African women

The treatment of infertility may involve the following:

• Lifestyle modification: This may include counseling on weight loss, stopping cigarette smoking,  reduction of alcohol usage, nutritious diets, etc.
   
• Drugs: Drugs can be administered by the health provider to address hormonal disorders. They are used for ovulation induction.
   
• Surgery: This can be done to open up blocked fallopian tubes, and take care of scarring  in the womb (uterine synaechiae) or in the pelvis that is caused by endometriosis. It can also be used to remove fibroids, where indicated.
   
• Assisted Reproductive Techniques (ART): These are medical procedures that are used to assist in the process of fertilization, they include: 
  • Intrauterine Insemination [IUI]: In Intrauterine Insemination, the sperm is collected and placed directly in the uterus of the woman when she is ovulating. 
  • In-vitro fertilization (IVF): The egg and sperm are collected and fertilized in the laboratory, then after some days, the fertilized egg [embryo] is placed directly into the uterus of the woman.
  • Intracytoplasmic sperm injection (ICSI): This is Another type of ART procedure.
  • Cryopreservation of gametes or embryos: A technique that involves freezing embryos or gametes for future use. 
  • Use of fertility medication: A type of ART that involves taking medication to stimulate egg production. This has been discussed above. 

 

How African women can lower their odds for infertility

To lower the odds for infertility, African women must do the following:

• African women must engage in exercises and be physically active to lower the risks of weight problems and weight–induced conditions.
   
• They must avoid smoking and excessive alcohol consumption so they don’t deplete the quality of eggs that are produced. 
   
• Practice safe sex to prevent the occurrence of sexually transmitted diseases, this means using protection and not having multiple sexual partners.
   
• Ensure that they go for regular checkups, this is done for early detection of STI’s, hormonal disorders and other chronic diseases that may result in infertility.
   
• Seek treatment for chronic diseases the moment they are noticed.
   
• African women should make sure that their meals are well-prepped and balanced with the necessary nutrition that their bodies require.
   
• They must be aware of environmental toxins like pesticides, radiation etc.

 

Treatment challenges of infertility in African women

African women face a lot of challenges when it comes to the treatment of infertility, these challenges are not limited to the following:

• Finances/High cost of Treatment: Some of the treatment options are not quite popular in African society, which makes them expensive and above the income of the average African woman. Women might be left to source for the funding of these treatments themselves without the help of their partners. As some women may not be financially buoyant to afford the treatment options, they opt for traditional methods that may not prove effective.

• Stigma: African women who have decided to use assisted reproductive methods like the In-vitro fertilization [IVF], Intrauterine Insemination [IUI] and Surrogacy, face backlash and stigma from society. Some of the babies that are conceived through these assisted methods are considered ‘artificial’ and sometimes rejected by society. The femininity or womanhood of women who have used these assisted reproductive methods is questioned or debated.

• Limited/Poor Access to Care: Quite a number of these treatments are not available in general hospitals. They are mostly done in specialized centers. These centers are not so accessible to the average African woman. Some of the treatment options or drugs are also difficult to get.

• Poor Understanding of Treatment Option: Myths and stereotypes exist about infertility treatment options, most African women and people around them, do not have a clear understanding of how these treatment options work. 

• Insufficient Social Support: The lack of support from husbands, other family members and the society in general affects women struggling with infertility adversely. Women are faced with finding solutions for their problems alone, they have to source for funds and sometimes go through the treatment without any form of emotional and financial support.

• Poor Education: There are no sensitisation programs to enlighten women and the society in general on the causes and risk factors for infertility. A lot of couples in the early stages of infertility do not deem it necessary to see their gynaecologist for an early diagnosis of the cause of their infertility. 

 

Conclusion

African women suffer a lot of consequences for infertility even when they might not be the contributing factor. Healthcare providers and advocates need to be active about enlightening the society on the causes and risk factors of infertility. Treatment options should be subsidized and made available to the average woman. Couples must be encouraged to seek help in the early stages of infertility. This is for early detection and treatment of underlying factors that may lead to infertility.   

Educating the society also reduces the discrimination and stigma towards women struggling with infertility, and in a way provides them with the emotional and social support that they require.

 

References

1. Chimbatata NBW, Malimba C. Infertility in Sub-Saharan Africa: A Woman’s Issue for How Long? A Qualitative Review of Literature. Open Journal of Social Sciences [online]. 2016; 4: 96 – 102. DOI: 10.4236/jss.2016.48012. Available from here. 

2. Gerais AS, Rushwan H. Infertility in Africa. Popul Sci [online]. 1992; 12: 25 - 46 Abstract available from here.

3. Ulla L. Infertility in Central Africa. Tropical Medicine & International Health [online]. 2003; 8[4]:354 – 367. doi: 10.1046/j.1365-3156.2003.01039.x. Available from here.

4. Esan DT, Nnamani KQ, Oluwagbami OO, Ramos CG. Infertility Affects the Quality of Life of Southwestern Nigerian Women and Their Partners. International Journal of Africa Nursing Sciences [online]. 2022; 17: doi: 10.1016/j.ijans.2022.100506. Available from here.

5. Abebe MS, Afework M, Abaynew Y. Primary and Secondary Infertility in Africa; Systematic Review with Meta-analysis. Fertil Res and Pract. [online]. 2020; 6[20]. doi: 10.1186/s40738-020-00090-3. Available from here.

6. Meheus A, Reniers J, Colletet M. Determinants of Infertility in Africa. Afr J Sex Transmi Dis. [online]. 1968; 2[2]: 31 – 5. Abstract available from here.

7. Emanuele MA, Wezeman F, Emanuele NV. Alcohol’s Effects on Female Reproductive Function. Alcohol Res. Health. [online]. 2002; 26[4]: 274 – 81. Available from here.

8. Dag Zo, Dilbaz B. Impact of Obesity on Infertility in Women. J Turk Ger Gynecol Assoc 2015; 16[2]: 111 – 7. doi: 10.5152/jtgga.2015.15232. Available from here.

9. Chrysoula B, Panagiotis DP, Gesthimani M, Meletios PN, Loukas A, Dimitrios GG, Christos SM. The Effect of Underweight on Female and Male Reproduction. Metabolism. 2020; 107. 154229. Abstract available from here.

 

Related:

Endometriosis: What You Need to Know

Fibroids: What Every African Woman Should Know

Hypothyroidism in Nigeria: Symptoms and Treatment

10 Disorders Linked with Hormonal Imbalance in African Women

Amenorrhea: Causes, Symptoms, Diagnosis and Treatment

 

Published: November 18, 2024

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