61 O b st e t r ic s a n d G y n e c O l O G y issn 2413-6077. iJMMr 2019 Vol. 5 issue 2 dOI 10.11603/IJMMR.2413-6077.2019.2.10388 RISK FACTORS FOR FEMALE INFERTILITY AT A TERTIARY HEALTH FACILITY IN AKURE, SOUTH-WEST NIGERIA T.A. Irinyenikan UNIVERSITY OF MEDICAL SCIENCES TEACHING HOSPITAL COMPLEX, AKURE, ONDO STATE, NIGERIA Background. The inability of couples to achieve pregnancy is a major cause of psycho-social problems in family relationship that could lead to marital disharmony. Objective. The aim of this study was to find out the possible risk factors for female infertility. Methods. A case-control design and a sample size of 400 (200 cases of infertility and 200 controls) were used in the study. Cases and controls were selected at random at the infertility and family planning clinic of the University of Medical Sciences Teaching Hospital Complex, Akure and were subjected to a predesigned interviewer administered questionnaire to collect the data. The cases were classified into primary and secondary infertility; binary and stepwise logistic regressions were used to generate the Odds ratio and 95% confidence interval of the possible risk factors and the level of significance was set at P<0.05. Results. The mean age of the women with infertility was 28.5±5.43 years and the mean age of those in the control group was 29.1±5.62 years. Among the cases, 155 (77.5%) had secondary infertility, while 45 (22.5%) had primary infertility. Significant risk factors for female infertility included presence of fibroids, having had fibroid operation, multiple sexual partners, previous abortion, polycystic ovary syndrome (PCOS), sexually transmitted infection (STI) and post abortion sepsis. Conclusion. The study showed that secondary infertility is still the most prevalent and the risk factors were multi factorial. Efforts should be intensified to reduce infertility due to preventable causes. KEY WORDS: female infertility; risk factors; fibroids; polycystic ovary syndrome; sexually transmitted infection. Corresponding Author: Dr. Theresa Azonima Irinyenikan, Consultant Obstetrician and Gynaecologist, Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, Uni- versity of Medical Sciences/University of Medical Sciences Teaching Hospital Complex, Akure, Ondo State, Nigeria. E-mail: tirinyenikan2017@gmail.com Introduction Infertility is the inability of a couple to achieve pregnancy over an average period of one year despite adequate, regular unprotected sexual intercourse [1]. WHO in 1991 estimated that between 8 and 12% of couples experienced some form of infertility during their reproductive lives, thus affecting 50 to 80 million worldwide, out of which 20-35 million couples in Africa expected to experience this problem [2]. This can be extrapolated to 3-4 million Nigeria couples suffering from infertility [3]. According to Ogunniyi in 1995, the prevalence of infertility in Sub-Saharan Africa was reported as ranging between 20-60% [4]. However, the estimate of infertile couples in Ile-Ife has been put at 19% by Okonofua in 1995 [5], although authors in previous studies in the other parts of Nigeria presented different ranging estimates. Causes of infertility could be due to female factors, male factors or both. Estimates show that in 35-40% of cases a man is infertile and in 35-40% of cases a woman is infertile while in 20-30% of cases, it is related to the combination of other factors [6]. Causes of female infertility include conditions that may damage the fallo- pian tubes, interfere with ovulation or cause hormonal imbalance [7]. These conditions in- clude pelvic inflammatory disease resulting from sexually transmitted infections, endo- metriosis, polycystic ovarian syndrome, pre- mature ovarian failure, uterine fibroids and envi ro nmental factors [7]. Other causes of infertility in females include post abortion sepsis, puerperal sepsis and age-related factors [8]. The risk factors for infertility can therefore be classified into: genital, endocrinal, develop­ mental and general factors [9]. Infertility can be primary, if a woman has never conceived before, or it can be secondary, if a woman has at least once conceived but may or may not have carried the pregnancy to term [10]. In resource-rich countries primary infer- International Journal of Medicine and Medical Research 2019, Volume 5, Issue 2, p. 61-68 copyright © 2019, TNMU, All Rights Reserved T.A. Irinyenikan 62 O b st e t r ic s a n d G y n e c O l O G y issn 2413-6077. iJMMr 2019 Vol. 5 issue 2 tility is much more common than secondary infertility, however the reverse is the case in Sub-Saharan Africa (SSA) [11]. In some African regions, the prevalence of secondary infertility is more than 30% [12]. The high secondary infertility rate in SSA is thought to be due to sexually transmitted infections (STIs) and medical interventions under unhygienic con- ditions, particularly during delivery or induced abortions [13]. Infertility is a global problem affecting people around the world, which cause and importance may vary according to the geo gra- phical location and socio­eco nomic condition; assessing risk factors for female infertility should be geographical considering the varia- tions that could arise from different regions. The aim of this study was to evaluate the risk factors for female infertility among cases of in- fertility presenting to a tertiary facility in Akure, South-West Nigeria, and the type of infertility prevalent among women there. This will further help to highlight the burden of this condition and subsequently help in policy making. Methods Study design The study used a matched case control design and was conducted at the infertility clinic and family planning clinic of the University of Medical Sciences Teaching Hospital Complex, Akure over a period of 2 years (July 2017- June 2019). Sample size calculation 3 𝑛𝑛𝑛𝑛 = � 𝑟𝑟𝑟𝑟 + 1 𝑟𝑟𝑟𝑟 � (�̅�𝑝𝑝𝑝)(1 − �̅�𝑝𝑝𝑝)(𝑍𝑍𝑍𝑍𝛽𝛽𝛽𝛽 + 𝑍𝑍𝑍𝑍𝛼𝛼𝛼𝛼2)2 (𝑝𝑝𝑝𝑝1 − 𝑝𝑝𝑝𝑝2)2 where n - proportion in each group; p2 - proportion exposed in the control group = 20%; p1 - proportion of cases exposed; p - average proportion of cases exposed; r=1 (equal number of cases and controls), using 80% power, Zβ= 0.84 and for 5% significance level using an odd ratio of 2.0, Z∝=1.96 P1=2.0(.20)/(.20)(2.0-1)+1=0.40/1.20=0.33, p =(.33+.20)= 0.265 𝑛𝑛𝑛𝑛 = 2 (. 256)(1 − .265)(.84 + 1.96)2 (.33 − .20)2 = 181 Sample size = 2 x 181= 362, this was rounded up to 400. A total of 200 cases and an age matched 200 controls enrolled into the study. Consent: Informed consent was obtained from all the clients who participated in this study. Ethical Approval: The ethical approval for the study was obtained from the Ethics Committee of the University of Medical Sciences Teaching Hospital Complex Akure, Ondo State. Protocol number 015, 12th May 2017. Inclusion criteria:Cases were infertile women who have attended the infertility clinic at least twice and the controls were age matched women attending the family planning clinic of the same hospital that gave their consent to participate in the study. Exclusion criteria: Women who had medications or surgery to induce pregnancy among the controls and those who did not give consent. Sampling technique Cases (infertile women) were selected at random from the infertility clinic of the hospital through a weekly visit till the required sample size was obtained. Controls involved fertile women, who attended the family planning clinic of the same hospital. The cases and controls were subjected to a predesigned interviewer administered questionnaire to collect socio- demographic data such as age, occupation, educational level, age at marriage; menstrual history such as age of menarche, regularity of menses, family history of infertility; relevant medical history such as diabetes mellitus, thyroid diseases, hypertension were also assessed; surgical history such as abdominal/pelvic surgeries were obtained. Information on probable gynaecological conditions that could cause infertility such as history of endometriosis, polycystic 2 21 2 /2 )(p )Z)(1)(( ) 1 ( p Zpp r r n − +−+ = αβ 181 )20.33.( )96.184)(.265.1)(265(. 2 2 2 = − +− =n where n – proportion in each group; p2 – proportion exposed in the control group = 20%; p1 – proportion of cases exposed; p̄ – average proportion of cases exposed; r=1 (equal num- ber of cases and controls), using 80% power, Zβ= 0.84 and for 5% significance level using an odd ratio of 2.0, Zα=1.96 p1=2.0(.20)/(.20)(2.0-1)+1=0.40/1.20=0.33, p̄=(.33+.20)= 0.265 3 𝑛𝑛𝑛𝑛 = � 𝑟𝑟𝑟𝑟 + 1 𝑟𝑟𝑟𝑟 � (�̅�𝑝𝑝𝑝)(1 − �̅�𝑝𝑝𝑝)(𝑍𝑍𝑍𝑍𝛽𝛽𝛽𝛽 + 𝑍𝑍𝑍𝑍𝛼𝛼𝛼𝛼2)2 (𝑝𝑝𝑝𝑝1 − 𝑝𝑝𝑝𝑝2)2 where n - proportion in each group; p2 - proportion exposed in the control group = 20%; p1 - proportion of cases exposed; p - average proportion of cases exposed; r=1 (equal number of cases and controls), using 80% power, Zβ= 0.84 and for 5% significance level using an odd ratio of 2.0, Z∝=1.96 P1=2.0(.20)/(.20)(2.0-1)+1=0.40/1.20=0.33, p =(.33+.20)= 0.265 𝑛𝑛𝑛𝑛 = 2 (. 256)(1 − .265)(.84 + 1.96)2 (.33 − .20)2 = 181 Sample size = 2 x 181= 362, this was rounded up to 400. A total of 200 cases and an age matched 200 controls enrolled into the study. Consent: Informed consent was obtained from all the clients who participated in this study. Ethical Approval: The ethical approval for the study was obtained from the Ethics Committee of the University of Medical Sciences Teaching Hospital Complex Akure, Ondo State. Protocol number 015, 12th May 2017. Inclusion criteria:Cases were infertile women who have attended the infertility clinic at least twice and the controls were age matched women attending the family planning clinic of the same hospital that gave their consent to participate in the study. Exclusion criteria: Women who had medications or surgery to induce pregnancy among the controls and those who did not give consent. Sampling technique Cases (infertile women) were selected at random from the infertility clinic of the hospital through a weekly visit till the required sample size was obtained. Controls involved fertile women, who attended the family planning clinic of the same hospital. The cases and controls were subjected to a predesigned interviewer administered questionnaire to collect socio- demographic data such as age, occupation, educational level, age at marriage; menstrual history such as age of menarche, regularity of menses, family history of infertility; relevant medical history such as diabetes mellitus, thyroid diseases, hypertension were also assessed; surgical history such as abdominal/pelvic surgeries were obtained. Information on probable gynaecological conditions that could cause infertility such as history of endometriosis, polycystic 2 21 2 /2 )(p )Z)(1)(( ) 1 ( p Zpp r r n − +−+ = αβ 181 )20.33.( )96.184)(.265.1)(265(. 2 2 2 = − +− =n Sample size = 2×181= 362, this was rounded up to 400. A total of 200 cases and an age matched 200 controls enrolled into the study. Consent: Informed consent was obtained from all the clients who participated in this study. Ethical Approval: The ethical approval for the study was obtained from the Ethics Com- mittee of the University of Medical Sciences Teaching Hospital Complex Akure, Ondo State. Protocol number 015, 12th May 2017. Inclusion criteria:Cases were infertile women who have attended the infertility clinic at least twice and the controls were age mat- ched women attending the family planning clinic of the same hospital that gave their consent to participate in the study. Exclusion criteria: Women who had medications or surgery to induce pregnancy among the controls and those who did not give consent. Sampling technique Cases (infertile women) were selected at random from the infertility clinic of the hospital through a weekly visit till the required sample size was obtained. Controls involved fertile women, who attended the family planning clinic of the same hospital. The cases and controls were subjected to a predesigned interviewer administered questionnaire to collect socio- demographic data such as age, occupation, educational level, age at marriage; menstrual history such as age of menarche, regularity of menses, family history of infertility; relevant medical history such as diabetes mellitus, thyroid diseases, hypertension were also asses- sed; surgical history such as abdominal/pelvic surgeries were obtained. Information on pro- bable gynaecological conditions that could cause infertility such as history of endometriosis, polycystic ovarian syndrome, presence of fib­ roids, sexually transmitted infections, genital infection following childbirth and previous abortion were obtained. The cases were classi- fied into primary or secondary infertility. Statistical Analysis The collected data were analysed using the computer package SPSS version 23. Descriptive tables were generated and binary logistic re- gression was used to generate the Odds ratio and the 95% confidence interval of the possible risk factors for infertility. These factors were further subjected to analysis using a stepwise logistic regression to identify the main predic- tors of female infertility. The statistical signi- ficance was set at p<0.05. Results During the study, 200 cases of female infertility were registered and 200 age-matched controls. The mean age of the women with infertility was 28.5±5.43 years old and the mean age of those in the control group was 29.1±5.62 years old. Among the cases, 155 (77.5%) pa- T.A. Irinyenikan 63 O b st e t r ic s a n d G y n e c O l O G y issn 2413-6077. iJMMr 2019 Vol. 5 issue 2 T.A. Irinyenikan tients suffered from secondary infertility, while 45 (22.5%) had primary infertility. The mean ages of those with secondary and primary infertility were 28.7±4.4 years old and 29.1±3.4 years old respectively. As presented in Table 1, 96 (61.9%) cases of secondary infertility and 70 (45.2%) of their control were traders, the risk of secondary infertility was statistically signifi­ cantly higher among the traders compare to their controls [OR=0.17, 95% CI=0.06-0.48, p=0.001]. Meanwhile, there was no statistically significant difference between the occupation of those with primary infertility and their control. The majority of the subjects practiced Christian religion, were married and had tertiary level of education with no statistically significant difference (p>0.05) in both groups. Table 2 showed the distribution of female infertility and the controls according to their gynaecological history. Most of the women in both groups were already married at the age of over 18 years old. Among those with secondary infertility, 94 (60.6%) had no living children but had abortions/ miscarriages in the past compare to their controls, where 92 (59.4%) already had ≥3 child­ ren, this was statistically significant, p=0.000. Similarly, the 45 (100%) of those with primary infertility have never been pregnant compare to their controls, where 31 (68.9%) had ≥3 living children. This was also statistically significant, p=0.000. Among those with secondary infertility, 31 (20.0%) had more than one sexual partner compare to 4 (2.6%) of the control, while 7 (15.6%) of those with primary infertility and 0 (0%) of the control had more than one sexual partner; this was also statistically significant, P=0.000. Among the cases, 91 (58.7%) of those with secondary infertility started their menses after the age of 15 years compare to 88 (56.8%) of their control, delayed menses was not a significant risk factor for infertility [OR=0.92, CI=0.59-1.45, p=0.730]. Only 10 (6.5%) of the cases of secondary infertility and 3 (6.7%) of their control reported family history of infertility, this was not a significant risk factor for infertility [OR=0.89, CI=0.35-2.26, p=0.813]. The analysis of cases of female infertility and the control according to the medical or surgical history showed that none of the subjects have ever had diabetes, thyroid disease or tuberculosis. Though, 10 (6.5%) of the cases of secondary infertility and 7 (4.5%) of their control reported to have had hyper- tension while 3 (6.7%) of the cases of primary infertility and none of their control reported to Table 1. Socio-demographic characteristics of cases of female infertility and control subjects Demographic factors 2o infertility cases (n=155) No (%) Control (n=155) No (%) OR (95% CI) P value 1o infertility cases (n=45) No (%) Control (n=45) No (%) OR (95% CI) P value Age 15-24 25-34 ≥35 0(0.0) 78(50.3) 77(49.7) 3(1.9) 73(47.1) 79(51.0) - 0.203 2(4.4) 26(57.8) 17(37.8) 1(2.2) 19(42.2) 25(55.6) 0.34 (0.06-1.96) 0.49 (0.27-0.91) 0.229 Occupation Civil/public servants Trading/ business Housewives/ applicants® 54(34.8) 96(61.9) 5(3.2) 64(41.3) 70(45.2) 21(13.5) 0.28 (0.10-0.79) 0.17 (0.06-0.48) 0.001 15(33.3) 26(57.8) 4(8.9) 22(48.9) 22(48.9) 1(2.2) 5.86 (0.59-57.78) 3.38 (0.35-32.55) 0.177 Religion Christian Islam 148(95.5) 7(4.5) 147(94.8) 8(5.2) 0.86 (0.31-2.45) 0.791 44(97.8) 1(2.2) 42(93.3) 3(6.7) 0.32 (0.06-1.62) 0.306 Marital status Single Married 3(1.9) 152(98.1) 1(0.6) 154(99.4) 0.3 3 (0.03-3.19) 0.314 0(0.0) 45(100) 2(4.4) 43(95.6) – 0.153 Educational level Primary Secondary Tertiary ® 13(8.4) 46(29.7) 96(61.9) 7(4.5) 38(24.5) 110(71.0) 0.47 (0.18-1.23) 0.72 (0.43-1.20) Reference 0.173 3(6.7) 12(26.7) 30(66.7) 2(4.4) 13(28.9) 30(66.7) 0.67 (1.10-4.28) 1.08 (0.42-2.75) Reference 0.887 ® = reference category 64 O b st e t r ic s a n d G y n e c O l O G y issn 2413-6077. iJMMr 2019 Vol. 5 issue 2 have had hypertension, this was not statistically significant [OR=0.69, CI=0.25­1.85, P=0.454]. However, 15 (9.7%) of secondary infertility cases have had fibroid operation compare with 1 (0.6%) of the control and the risk of secondary infertility was significantly higher than the control [OR=0.06, 95% CI=0.01-0.47, P=0.007]. Also, 5 (11.1%) of those with primary infertility and none of the control have had fibroid operation, the risk of primary infertility was significantly higher than the control, P=0.021 (Table 3). Table 2. Distribution of cases of female infertility and controls according to their gynaecological history Factors 2o infertility cases (n=155) No (%) Control (n=155) No (%) OR (95%CI) P value 1o infertility cases (n=45) No (%) Control (n=45) No (%) OR (95%CI) P value Age at marriage <18 ≥18 None 2(1.3) 151(97.4) 2(1.3) 0(0.0) 155(100) 0(0.0) – 0.132 0(0.0) 45(100) 0(0.0) 1(2.2) 43(95.6) 1(2.2) – 0.360 Parity 1 2 ≥3 None 46(29.7) 13(8.4) 2(1.3) 94(60.6) 20(12.9) 43(27.7) 92(59.4) 0(0.0) – 0.000 0(0.0) 0(0.0) 0(0.0) 45(100) 2(4.4) 12(26.7) 31(68.9) 0(0.0) – 0.000 Age at 1st menses <15® ≥15 64(41.3) 91(58.7) 67(43.2) 88(56.8) 0.92 (0.59-1.45) 0.730 23(51.1) 22(48.9) 17(37.8) 28(62.2) 0.58 (0.32-1.05) 0.203 Family history of infertility Yes No 10(6.5) 145(93.5) 9(5.8) 146(94.2) 0.89 (0.35-2.26) 0.813 3(6.7) 42(93.3) 0(0.0) 45(100) – 0.078 No sexual partner 1 >1 124(80.0) 31(20.0) 151(97.4) 4(2.6) 9.43 (3.24-27.46) 0.000 38(84.4) 7(15.6) 45(100.0) 0(0.0) – 0.006 Table 3. Distribution of cases of female infertility with controls according to their medical/surgical history Medical conditions 2o infertility cases (n=155) No (%) Control (n=155) No (%) OR (95%CI) P value 1o infertility cases (n=45) No (%) Control (n=45) No (%) OR (95%CI) P value Diabetes Yes No 0(0.0) 155(100) 0(0.0) 155(100) – – 0(0.0) 45(100) 0(0.0) 45(100) – – Hypertension Yes No 10(6.5) 145(93.5) 7(4.5) 148(95.5) 0.69 (0.25-1.85) 0.454 3(6.7) 42(93.3) 0(0.0) 45(100) – 0.078 Thyroid Yes No 0(0.0) 155(100) 0(0.0) 155(100) – – 0(0.0) 45(100) 0(0.0) 45(100) – – Tuberculosis Yes No – 155(100) – 155(100) – – – 45(100) – 45(100) – – Fibroid operation Yes No 15(9.7) 140(90.3) 1(0.6) 154(99.4) 0.06 (0.01-0.47) 0.000 5(11.1) 40(88.9) 0(0.0) 45(100) – 0.021 Other operation Yes No 1(0.6) 154(99.4) 0(0.0) 155(100) – 0.317 0(0.0) 45(100) 0(0.0) 45(100) – – T.A. Irinyenikan 65 O b st e t r ic s a n d G y n e c O l O G y issn 2413-6077. iJMMr 2019 Vol. 5 issue 2 T.A. Irinyenikan Table 4 presents the analysis of cases of infertility and the control according to their gynaecological conditions. The gynaecological conditions in the subjects included fibroids, which was present in 46 (29.7%) cases of secondary infertility compare to 11 (7.1%) of their control, the risk of secondary infertility among them was significantly higher than their control [OR=0.18, 95% CI=0.09-0.37, P=0.00]. Similarly, among the cases of primary infertility, 15 (33.3%) had fibroids compare to only 1 (2.2%) of their control, the risk of primary infertility was significantly higher than the control [OR=0.07, 95%CI=0.008-0.64, P=0.00]. Also, among the cases of secondary infertility, 50 (32.3%) had endometriosis, 35 (22.6%) of their control had similar condition, while in the cases of primary infertility 15 (33.3%) had endometriosis and 10 (22.2%) had the condition, there was no statistically significant difference in both groups at p>0.05. Among the 2 groups, 114 (73.5%) of those with secondary infertility had previous abortion compare to 53 (34.2%) of their control while none was reported in the cases of primary infertility. The risk of secondary infertility was significantly higher than the control [OR=0.19, 95% CI=0.12-0.30, p=0.000]. Post abortion sepsis was reported in 30 (19.4%) of cases of secondary infertility and only 10 (6.5%) of the control with a statistically signi- ficant higher risk among the cases [OR=0.29, 95% CI=0.14-0.61, p=0.001]. Another gynaeco- logical condition prevalent was polycystic ovary syndrome (PCOS), which was reported in 53 (34.2%) cases of secondary infertility and 7 (4.5%) of their control, the risk of PCOS among those with secondary infertility was significantly higher than their control, [OR=0.09, 95% CI=0.04-0.21, p=0.000] while in the cases of pri- mary infertility, it was reported in 18 (40.0%) and 2 (4.4%) of their control and the risk of PCOS was also significantly higher than the control [OR=0.01, 95% CI=0.01-0.52, p=0.000]. Sexually transmitted infection was reported in 47 (30.3%) cases of secondary infertility and 18 (11.6%) of their control with a significantly higher risk of this condition among these cases [OR=0.30, 95% CI=0.17-0.55, p=0.000), while Table 4. Analysis of cases of female infertility and the controls according to their gynaecological conditions Gynaecological conditions 2o infertility cases (n=155) No (%) Control (n=155) No (%) OR (95%CI) P value 1o infertility cases (n=45) No (%) Control (n=45) No (%) OR (95%CI) P value Endometriosis Yes No 50(32.3) 105(67.7) 35(22.6) 120(77.4) 0.61 (0.37-1.02) 0.056 15(33.3) 30(66.7) 10(22.2) 35(77.8) 0.79 (0.17-3.69) 0.239 Fibroid diagnosis Yes No 46(29.7) 109(70.3) 11(7.1) 144(92.9) 0.18 (0.09-0.37) 0.000 15(33.3) 30(66.7) 1(2.2) 44(97.8) 0.07 (0.008-0.64) 0.000 Previous abortion Yes No 114(73.5) 41(26.5) 53(34.2) 102(65.8) 0.19 (0.12-0.30) 0.000 0(0.0) 45(100) 16(35.6) 29(64.4) – 0.000 PCOS Yes No 53(34.2) 102(65.8) 7(4.5) 148(95.5) 0.09 (0.04-0.21) 0.000 18(40.0) 27(60.0) 2(4.4) 43(95.6) 0.01 (0.01-0.52) 0.000 Menstrual cycle Regular Irregular 141(91.0) 14(9.0) 147(94.8) 8(5.2) 0.55 (0.22-1.35) 0.184 37(82.2) 8(17.8) 41(91.1) 4(8.9) 0.83 (0.10-6.71) 0.215 Genital infection Yes No 8(5.2) 147(94.8) 10(6.5) 145(93.5) 1.26 (0.48-3.30) 0.627 0(0.0) 45(94.8) 4(8.9) 41(91.1) – 0.061 STI Yes No 47(30.3) 108(69.7) 18(11.6) 137(88.4) 0.30 (0.17-0.55) 0.000 6(13.3) 39(86.7) 7(15.6) 38(84.4) 1.11 (0.21-5.89) 0.764 Post abortion sepsis Yes No 30(19.4) 125(80.6) 10(6.5) 145(93.5) 0.29 (0.14-0.61) 0.001 0(0.0) 45(100) 3(6.7) 42(93.3) 0.71 (0.0-0.0) 0.078 66 O b st e t r ic s a n d G y n e c O l O G y issn 2413-6077. iJMMr 2019 Vol. 5 issue 2 among the cases of primary infertility 6 (13.3%) and 7 (15.6%) of their control reported to have had this condition, this was not statistically significant, p>0.05. Among the cases of secon­ dary infertility, 8 (5.2%) and 10 6.5%) of the control had genital infection, there was no sta- tistically significant difference in both groups. Menstrual irregularity was found in 14 (9.0%) cases of infertility compare to 8 (5.2%) of their control and 8 (17.8%) of primary in fertility compare to 4 (8.9%) of the control, this was not statistically significant. Table 5 showed various predictors of secondary and primary infertility using stepwise logistic regression analysis of the various independent risk factors for infertility. Table 5. Stepwise logistic regression to identify predictors of female infertility Independent variable B S.E. (Standard Error) Test P. value OR 95% CI Model (1): For Secondary infertility Fibroid diagnosis 1.113 0.426 6.838 0.009 3.04 1.32-7.01 Fibroid operation 1.621 1.151 1.984 0.159 5.06 0.53-48.21 PCOS 2.213 0.45 24.174 0.00 9.14 3.78-22.08 STI 0.746 0.359 4.325 0.038 2.11 1.04-4.26 Post abortion sepsis -0.271 0.473 0.329 0.57 0.76 0.30-1.93 Previous abortion 1.544 0.294 27.564 0.000 4.68 2.63-8.33 Constant -12.393 2.50 24.487 Model (2):For Primary infertility Fibroid diagnosis 2.508 1.118 5.034 0.025 12.28 1.37-109.86 PCOS 2.884 1.13 6.489 0.01 17.88 1.94-164.51 STI -0.052 0.84 0.004 0.951 0.949 0.18-4.94 Constant -12.393 2.50 24.487 0.000 In Model 1, among the various significant factors detected by the binary logistic regression analysis for secondary infertility only the presence of fibroids [OR=3.04, 95% CI=1.32­7.01, p=0.009], polycystic ovary syndrome [OR=9.14, 95% CI=3.78-22.08, P=0.00], sexually transmitted infection [OR=2.11, 95% CI=1.04-4.26, p=0.038] and previous abortion [OR=4.68, 95% CI=2.63- 8.33, p=0.000] were predictors of secondary infertility. In Model 2, the presence of fibroids [OR=12.28, 95% CI=1.37-109.86, p=0.025] and polycystic ovary syndrome [OR=17.88, 95% CI=1.94-164.51, p=0.01] were the predictors of primary infertility. Discussion The study showed that secondary infertility was commoner among the women (77.5%) than primary infertility (22.5%), which is in keeping with studies carried out in other parts of Nigeria [11,12,13]. It further highlights the burden of secondary infertility which is more prevalent in Sub-Saharan African countries compared to the Western world [14].The demographic charac- teristics of the subjects showed that most of the women were already married and possibly in a sexual relationship to enable one ascertain if there are issues concerning their fertility. Other factors such as the woman’s age, reli- gion, educational level had no impact on fertility as against a similar study which reported a decrease in a woman’s fertility with increasing age [15]. These factors therefore were not risk factors for infertility among our women. Menstrual irregularity was seen in some of the women with secondary infertility though not statistically significant and therefore suggest that this has no strong effect as a risk factor for infertility among our women. However, having multiple sexual partners was a significant risk factor for infertility among the women, which further confirmed the increase in sexually transmitted infection which was also reported among the women with secondary infertility. Sexually transmitted infections are transmitted through sexual activity with an infected partner and a major cause of secondary infertility in Sub-Saharan Africa [6]. This study also highlights gynaecological conditions such as the presence of fibroids and previous abdominal surgeries for fibroids as risk factors for female infertility which is in keeping with another study [16]. Large fibroids may cause infertility by impairing the uterine lining, blocking the fallopian tube, distorting the shape of the uterine cavity or altering the T.A. Irinyenikan 67 O b st e t r ic s a n d G y n e c O l O G y issn 2413-6077. iJMMr 2019 Vol. 5 issue 2 T.A. Irinyenikan position of the cervix. Also, following pelvic surgery, postsurgical or post infective uterine or abdominal adhesions that result may restrict the movement of ovaries and fallopian tubes and cause infertility. Previous abortion and post abortion sepsis were significant risk factors for secondary infertility in this study. This finding has also been reported in another study in Nigeria where induced abortion and post abortion sepsis were found to affect future fertility [17]. This may be as a result of repeated injuries to the uterine lining from multiple dilatation and curettage which can cause adhesions within the uterus thus leading to secondary amenorr- hea and infertility. However, genital infection did not have any significant effect on the cause of infertility, this could have been due to increase access to health care and the presence of skilled birth attendants during delivery. This study showed ovarian dysfunction as a result of polycystic ovary syndrome to be a significant cause of both primary and secondary infertility among the women, similar studies have shown that nearly 10% of infertile women are diagnosed with reduced ovarian dysfunction and polycystic ovary syndrome implicated as a common cause of ovula tion disorder in women of childbearing age [18,19,20]. In this study the main predictors of female infertility were the presence of fibroids, poly­ cystic ovary syndrome, sexually transmitted infections and previously induced abortions for unwanted pregnancies. These findings have further revealed the great impact of repro- ductive infections and hormonal imbalance as major causes of female infertility. Conclusion Female infertility is still a major public health issue and its cause could be multi fac- torial. Secondary infertility remains the most prevalent type in the region mostly due to tubal damage as a result of increase in sexually transmitted infections and previous induced abortions. Though, hormonal cause such as polycystic ovary syndrome may not be under our control, reproductive infections from sexual activity could be curtailed by preventing unsafe sex and prompt treatment of diseases resulting from sexually transmitted infections. Efforts should be intensified to prevent unsafe abortions which could lead to infertility in the future. Acknowledgements. I acknowledge the Consultant Obstetricians and Gynaecologists of the University of Medical Sciences Teaching Hospital Complex Akure for allowing to use their patients for the study, the research assistants, who helped in the collection of the data and the statistician, who analysed the data. Funding This research received no external funding. Conflict of Interests The author declares no conflict of interest. Фактори ризику розВитку Жіночого Безпліддя на третинному ріВні надання медичноЇ допомоги у акуре, піВденно-західна нігерія T.A. Irinyenikan UNIVERSITY OF MEDICAL SCIENCES TEACHING HOSPITAL COMPLEX, AKURE, ONDO STATE, NIGERIA Вступ. Неможливість пари народити спільних дітей є однією з головних психо-соціальних проблем, що призводить до дисгармонії подружніх стосунків. Мета дослідження встановити можливі фактори ризику розвитку жіночої неплідності. Методи. У дослідження було залучено 400 жінок (200 – з неплідністю та 200 осіб склали групу контролю). Жінок було обрано методом випадкової вибірки у клініці планування сім’ї при Навчально- лікувальному комплексі Університету медичних наук, Акуре. Усі досліджувані заповнювали спеціально розроблений опитувальник. Усі випадки було класифіковано на первинне та вторинне непліддя. Застосовано статистичний регресійний аналіз: бінарну та непряму логістичну регресію, рівень значущості p<0.05. Результати. Середній вік жінок з неплідністю склав 28,5±5,43 роки, контрольної групи – 29,1±5,62 роки. У 155 (77,5%) випадках мала місце вторинна неплідність, і лише у 45 (22,5%) – первинне безпліддя. Статистично значущими факторами ризику були наявність фібротичних змін, оперативні втручання з їх приводу, кілька сексуальних партнерів, попередні аборти, синдром полікистозних яйників, хвороби, що передаються статевим шляхом та постабортний сепсис. 68 O b st e t r ic s a n d G y n e c O l O G y issn 2413-6077. iJMMr 2019 Vol. 5 issue 2 References 1. Vander BM, Wyns C. Fertility and Infertility definition and epidemiology. Clin Biochem.2018; 62:2­10. 2. Ombelet W. Global access to infertility care in developing countries: a case of human rights, equity, and social justice. FVV Obgyn 2012; Monograph: 7–16. 3. Mascarenhas MN, Cheung H, Mathers CD, Stevens GA. 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Longitudinal interviews of couples diagnosed with diminished ovarian reserve undergoing fragile X permutation testing. J Genet Couns. 2014;23(1): 97-107. doi:10.1007/s10897­013­9616­0 20. Tsai YH, Wang TW, Wei HJ, et al. Dietary intake, glucose metabolism and sex hormones in women with polycystic ovary syndrome (PCOS) compared with women with non- PCOS-related infertility. Br J Nutr. 2013;109(1):2190­8. doi:10.1017/S0007114512004369 Received 13 September 2019; revised 11 October 2019; accepted 24 October 2019. This is open access article distributed under the Creative Com- mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Висновки. Дослідження показало, що вторинне безпліддя все ще переважає у структурі захворюваності, фактори ризику – мульфакторіальні. Зусилля, спрямовані на зменшення розвитку непліддя через фактори, які можна попередити, повинні бути посилені. KEY WORDS: жіноче безпліддя; фактори ризику; фіброз; синдром полікистозних яйників; хвороби, що передаються статевим шляхом. Information about the author Dr. Theresa Azonima Irinyenikan – Consultant Obstetrician and Gynaecologist, department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, University of Medical Sciences/University of Medical Sciences Teaching Hospital Complex, Akure, Ondo State, Nigeria. ORCID 0000­0002­5594­037X, e­mail: tirinyenikan2017@gmail.com T.A. Irinyenikan