FEMALE AND MALE INFERTILITY IN NIGERIA Studies on the epidemiology of infertility in Nigeria with special reference to the role of genital tract infections and sexual and reproductive risk factors Friday Ebhodaghe Okonofua

Background: Infertility is a major public health problem in Nigeria, contributing to inappropriate contraceptive behavior and poor sexual and reproductive health of women. To date, there is a paucity of scientific information relating to the factors that place men and women at risk of infertility in this population. Objectives: The objectives of this thesis are: (1) to provide substantive scientific data on the epidemiological and reproductive health risk factors predisposing to male and female infertility in Nigeria, and (2) to make recommendations on the design of interventions for reducing the prevalence of infertility in the country. Methods: Endocervical swabs from 92 infertile women and 86 pregnant controls were compared for rates of isolation of Neisseria gonorrhoeae (NG), Candida albicans (CT) and other facultative organisms (Study I). Sixty infertile women were then compared with 53 fertile controls for antibodies to NG and T. pallidum (Study II). In Study III, 150 infertile males were compared with 150 fertile controls for selected risk factors for infertility. We compared 81 infertile women and 81 agematched pregnant controls for sexual and reproductive risk factors and Chlamydia trachomatis (CT) antibodies (Study IV). Clinical evidence for infections as causes of male and female infertility was solicited with a protocol that investigated 192 infertile couples (Paper V). Results: The rate of isolation of NG from the endocervix was 17.4% among infertile women and 10.5% in fertile women (p>0.05). Nearly 15% of infertile women had past episodes of pelvic inflammatory disease (PID) and 26% had had induced abortions. Infertile women were more likely to report past lower abdominal pains (p<0.01), yellow vaginal discharge (p<0.004) and whitish vaginal discharge (p<0.02) than fertile women. Sixteen infertile women (26.7%) had antibodies to NG in their sera compared with four fertile controls (7.5%) (p<0.02; OR 4.5). Multivariate analysis showed that male infertility was significantly associated with self-reporting of episodes of recurrent penile discharge (OR 7.8; 95%CI 2.9–21.5), recurrent pain on micturition (OR 2.2; 95%CI: 1.02–4.71, p<0.04), genital ulcers (OR 8.8; 95%CI 3.7–9.2), use of native medications (OR 11.89; 3.4–41.5) and heavy alcohol consumption (OR 6.05; 95%CI 1.81–22.3). Men who reported that they used patent medicine sellers for these symptoms were more likely to be infertile than those using more effective methods of treatment (OR=8.2; 95%CI 2.1–36.6). The prevalence of serum CT antibodies was significantly higher in infertile women (64.2%) than in pregnant controls (17.3%) (p<001). However, the strongest independent predictors of infertility in the model were vaginal discharge, more than three lifetime sexual partners and primary and secondary level education. Among 190 infertile couples investigated, the main causes of infertility were complications arising from past episodes of genital tract infections. Conclusions: These results show that past episodes of RTIs, correlates of sexual activity and antibodies against NG and CT are the most significant predictors of infertility in this population. The results demonstrate the important role of RTIs and STIs in the epidemiology of male and female infertility in Nigeria. We believe that a public health approach that integrates the prevention of STIs and RTIs within existing services for women and men would reduce the burden of infertility and its consequences in Nigeria.