https://imcjms.com/public Ibrahim Medical College Journal of Medical Science https://imcjms.com/public/registration/journal_full_text/204 Sun, 30 Apr 2017 15:00:18 +0000 Infertility is an experience that strikes at the very core of a woman’s life and as a whole her family and society. Studies in Bangladesh to evaluate the factors are difficult to come by. This case control study was carried out from Jan 2010 to June 2010 to find out the factors associated with secondary infertility. A total of 70 cases were selected from the infertility unit of Bangabandhu Sheikh Mujib Medical University and 70 unmatched controls from the same hospital attending the pediatrics unit with their children were also recruited. Data were collected by interview and review of documents. No age difference was noticed between the cases (29.26 ± 4.13) and controls (29.21 ± 3.95). Association of secondary infertility was found with body mass index (p=0.036), previous bad obstetric history (p = 0.011) and previous caesarian delivery (p=0.044). Women with secondary infertility were more than four times more likely to have gynecological problem(s) than their fertile counterparts [OR 4.76 with 95% CI (2.018-11.270)]. The factors identified in this study might help the policy makers in designing prevention and health care programmes and thus reducing the hidden burden of secondary infertility. Address for Correspondence:Dr. Hasina Momtaz, Lecturer, Department of Community Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam, Avenue, Shahbagh, Dhaka-1000, Bangladesh   Secondary infertility refers to couples who are unable to conceive after one year of unprotected intercourse after a previous pregnancy in the reproductive age group. Globally, approximately, 10-15% of couples are infertile, affecting more than 80 million people worldwide. Secondary infertility outnumbers primary infertility.1 Either the male or female partners can be responsible for infertility in around 30% cases or both are involved in another 25 to 30% cases. In the remaining 10 to 15% case no cause could be found, which is known as unexplained infertility.4 Many factors including infectious, environmental, genetic, and even dietary in origin can contribute to infertility. Because of the under reporting of secondary infertility in institution based studies, information on the causes of infertility is likely to consistently underestimate the role of infection, which is the most frequent cause of secondary infertility.5 In western countries, obesity affects approximately half of the general population and is thus a common problem among the infertile population. Obese women have a higher prevalence of infertility compared with their lean counterparts. The majority of women with an ovulatory disorder contributing to their infertility have polycystic ovary syndrome (PCOS) and a significant proportion of women with PCOS are obese. Ovulation disorders and obesity-associated infertility represent a group of infertile couples that are relatively simple to treat.7 In Bangladesh very little is known about the status of infertility. However, the problem is considered quite prevalent. According to a WHO survey report, infertility rate was found to be 6.9 percent and from BIRPERHT’s Reproductive Health Care Need Study (RHCNS), 1996 primary infertility rate was estimated at 3.2 percent and secondary infertility rate was found to be 2.9 percent.9 Infertility has been relatively neglected as both a health problem and a subject for social science research in South Asia, as well as the developing world. The general thrust of both programmers and research has been on the correlates of high fertility and its relation rather than on understanding the context of infertility, its cause and consequences. Moreover, in pronatalist cultures such as those of India, and South Asia more generally, the consequences of infertility for women can be devastating.10   This case control study was conducted on 70 cases and 70 unmatched controls for a period of 6 months commencing from January 2010. Women who failed to conceive after 1 year of unprotected intercourse with a history of one previous conception, and coming to the infertility unit of Bangabandhu Sheikh Mujib Medical University (BSMMU) during data collection period, were taken as cases. Women having a second child and attending the pediatric unit of BSMMU for treatment or vaccination of their baby were taken as controls. The cases were selected by purposive sampling. Data were cleaned, edited, coded and computed with the help of soft-ware SPSS version 11.5. Quantitative data were analyzed to find out the mean and standard deviation and mean differences were tested by Student’s t-test. Qualitative data were analyzed to estimate the proportion and were tested by c2 test. Odds Ratio with 95% confidence interval was estimated. Results     Cases, on average, got married at a later age (20.80 ± 4.70) than the controls (19.89 ± 3.20). Use of hormonal contraception was more common in cases (54.3%) than in controls (48.6%). There was no difference in menstrual hygiene. More than half of the infertile women (55.7%) had poor delivery outcome in their first pregnancy whereas only one third of controls had similar findings (34.3%). Secondary infertile couples were 2.4 times more likely to have a bad obstetric outcome in their previous pregnancy than fertile couples [OR 2.68 with 95% CI (1.01 to 7.12)]. The chance of developing secondary infertility is 2.68 times more with previous caesarian delivery than normal vaginal delivery (Table-2). Table-2: Distribution of reproductive characteristics between cases and controls       Although the distribution was not significantly different, it showed a higher proportion of class II obese in cases (14.3%) than in controls (2.99%). Association was found between body mass index (BMI) and secondary infertility. Cases were, on average, with 1.5 higher BMI than in controls (p=0.036, Table- 4). Table-4: Distribution of body mass index between cases and controls   The study was undertaken to gain insight into the problem of infertility. The relationship between secondary infertility and its associated factors is difficult to study. Prospective studies need large cohorts, which are difficult and expensive to follow and have the additional drawback of losing the subjects in the control group. This case control study was carried out in 70 cases and 70 unmatched controls to find out the factors associated with secondary infertility. Although it was not planned, controls matched with cases in relation to age and other socio-demographic variables as no difference was noticed between the two groups. But a previous study found that prevalence of secondary infertility increased with age from 4% in women aged 15-24 years to 17% in those >39 years.2 Pelvic surgery shows, proportion of caesarian section was more in controls (63.6%) than cases (48.1%). But the number of pelvic surgery was more in cases than controls. There was no significant difference in pelvic surgery between cases and controls. But in other studies, pelvic surgery was found to be a contributing factor for development of secondary infertility.13 This difference probably was attributed to differences in sample characteristics. Detection of any gynecological factors that may be associated with secondary infertility was explored by checking the ultasonography report. Association was found between abnormal ultrasonogram findings with secondary infertility. Risk of developing secondary infertility was 4.76 times more with abnormal findings in ultra sonogram report than with normal findings. The abnormal finding includes PCOS,fibroid uterus and others. And the distribution shows higher proportion of abnormal findings contributing to PCOS. Association of secondary infertility with PCOS was also found in other studies.15 Conclusion   1.   Ali T, Sami N, Khuwaja A. Are unhygienic practices during the menstrual, partum and postpartum periods risk factors for secondary infertility? J Health Popul. Nutr 2007; 25(2): 189-194. 3.   Papreen N, Sharma A, Sabin K, Begum L, Ahsan SK, Baqui AH. Living with infertility: experiences among Urban slum populations in Bangladesh. Bangladesh Health Matters 2000; 8(15): 33-44. 5.   Barbara T. The epidemiology of infertility in Aberdeen Medical Sociology Unit. Aberdeen Br Med J 1990; 301: 148-152. 7.   Wilkes S, Murdoch E, Alison D. Obesity and female fertility: primary care perspective. Journal of Family Planning and Reproductive Health Care 2009; 35: 181-185. 9.   Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERHT), Briefing paper on Assessment of Reproductive Health Care needs and Review of Services provided at the level of Thana, Union and Village, Dhaka, Bangladesh, 1997; 5: 1-4. 11.Tzonou A, Hsieh C, Trichopoulos D, Aravandinos D, Kalandidi A, Margaris D et al. Induced abortions, miscarriages, and tobacco smoking as risk factors for secondary infertility. J Epidemiol Community Health 1993; 47(1): 36-39. 13.Homan M, Davies R, Norman: The impact of lifestyle factors on reproductive performance in the general population and those undergoing infertility treatments. Human Reproduction and Embryology oxfordjournals.org 2007. 15.Dewailly S, Hieronimus P, Mirakian N. Polycystic ovary syndrome (PCOS). D’Endocrinologe 2010; 71(1): 8-13. 2026 Ibrahim Medical College. All rights reserved.