Menoufia Medical Journal

: 2019  |  Volume : 32  |  Issue : 4  |  Page : 1365--1370

Infertility and related risk factors among women attending rural family health facilities in Menoufia Governorate

Zakaria F Sanad1, Nora Abd El-Hady Kalil2, Eman S. Abd El-Rahman Beddah3,  
1 Department of Obstetric and Gynaecology, Faculty of Medicine, Menoufia University, Egypt
2 Department of Family Medicine, Faculty of Medicine, Menoufia University, Egypt
3 Department of Family Medicine, Menoufia University, Menoufia Governorate, Egypt

Correspondence Address:
Eman S. Abd El-Rahman Beddah
Horeen, Birkit Alsaba City, Menoufia Governorate


Background Infertility is perceived as a problem across virtually all cultures and societies and affects 10–15% of couples in their reproductive age. Objective The current study aimed to assess the prevalence of infertility among women attending the studied health facilities and explore the different factors related to infertility among the studied group. Patients and methods The cross-sectional descriptive study was conducted on 320 married women in the child-bearing period. The calculated sample was collected from four primary health-care facilities which were randomly selected. Women were interviewed by a predesigned questionnaire. Results The prevalence of infertility among the studied group was 25%. The prevalence of primary and secondary infertility was 9 and 16%, respectively. Infertility was significantly associated with overweight and obesity (P < 0.05), sedentary lifestyle (P < 0.001), irregular menstruation (P < 0.001), history of pelvic inflammatory disease (P < 0.001), and passive smoking (P < 0.05). Conclusion There are numerous risk factors affecting infertility in the Egyptian women, and many of them are preventable.

How to cite this article:
Sanad ZF, El-Hady Kalil NA, El-Rahman Beddah ES. Infertility and related risk factors among women attending rural family health facilities in Menoufia Governorate.Menoufia Med J 2019;32:1365-1370

How to cite this URL:
Sanad ZF, El-Hady Kalil NA, El-Rahman Beddah ES. Infertility and related risk factors among women attending rural family health facilities in Menoufia Governorate. Menoufia Med J [serial online] 2019 [cited 2020 Apr 8 ];32:1365-1370
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Full Text


Infertility is defined as the failure to achieve pregnancy after 12 months or more of regular, unprotected sexual intercourse, without the use of contraception [1].

The WHO estimated that 25% of couples in developing countries have been affected by infertility during their lifetime [2] and about 20% of couples in developed countries [3].

Epidemiological data indicate that infertility is estimated to involve as many as 186 million people worldwide. It is viewed by experts to be a problem that affects 15–20% of couples [4].

The origin of infertility is due to male or female factor, with an estimated range from 12 to 28%; 20–30% of infertility cases are due to male infertility; 20–35% are due to female infertility; and 25–40% are due to combined problems in both partners. In 10–20% of cases, no cause is found [5].

There are multiple risk factors that affect female fertility. They include: age, obstetrical history, smoking and drinking patterns, menstruation, BMI index, and lifestyle factors [6]. Other risk factors such as general demographic factors, marriage, and child-bearing status, including the age at marriage, marriageable age, number of pregnancies and abortions, etc., disease history (PCO, eating disorders, or sexually transmitted diseases) and menstruation status, including whether it is regular or not, the presence or absence of dysmenorrheal [7].

The study was conducted to assess the prevalence of infertility to identify the main risk factors associated with infertility among Egyptian women in order to aid in providing a more suitable care for them in the future.

 Patients and Methods

The study is a cross-sectional, descriptive study. The study setting was selected through the multistage random sampling technique. Birket Alsaba District was selected to represent Menoufia Governorate in Egypt. Then (Horeen) village was randomly selected from 12 villages in Birkat Alsaba District and its FHU represents the rural area of the study.

The calculated sample size was 320; it was determined using the formula for sample size calculation for a definite population (2786 women in the child-bearing period), considering infertility in Egypt affects 12% of Egyptian couples [8], with a power of 80%, confidence interval of 95%, and 0.05 as the absolute sampling error that can be tolerated.

All participants were interviewed using a validated self-designed questionnaire. The questionnaire included: personal data for the assessment of sociodemographic characteristics, questions assessing lifestyle characteristics, and different factors possibly related to infertility such as menstrual history, obstetric history, gynecological history, contraceptive history, and medical and surgical history.

Ethical approval

The study was approved by the Ethics Committee of the Faculty of Medicine, Menoufia University. Informed consent was obtained from all participants after simple and clear explanation of the research objectives and methodology.

Statistical analysis

Data were analyzed using the statistical package for the social sciences, Version 21.0. (using IBM personal computer, IBM SPSS Statistics for windows, Armonk, NY: IBM Corp). Quantitative data (age) were expressed as mean and SD. Qualitative data were expressed as number and percentage and were analyzed applying the χ2 test.


The study showed the prevalence of infertility among the studied group was 25%. The prevalence of primary and secondary infertility was 9 and 16%, respectively, among the studied participants [Figure 1].{Figure 1}

[Table 1] shows significant difference between fertile and infertile groups regarding lifestyle factors as more than half (51.2%) of the infertile group were overweight and more than 60% of them were exposed to passive smoking. Also, 55% of them had a sedentary lifestyle. However, 62% of the infertile group had no caffeine consumption.{Table 1}

[Table 2] shows a comparison between fertile and infertile groups regarding gynecological history that there is a statistically significant difference between fertile and infertile groups for menstrual pattern as 27.5% of the infertile group had irregular cycle versus 2.5% of the fertile group. Genital infection such as bacterial vaginosis and pelvic inflammatory disease (PID) was significantly more prevalent among the infertile group (66.7 and 75%, respectively). As regards the frequency of genital infection, 82% of the fertile group had no infection in the last year versus only 18% of the infertile group. Dyspareunia and postcoital bleeding were significantly more frequent among infertile women, 56 and 78%, respectively. Also, infertility was significantly more prevalent among patients who had a history of appendectomy others; 65.9% (P < 0.001).{Table 2}

[Table 3] shows that a history of ectopic pregnancy and history of dilatation and curettage were significantly more frequent among the infertile group, 71.4 and 60%, respectively. However, cesarean section, history of abortion, and a history of complication in the last pregnancy were significantly more frequent among the fertile group.{Table 3}

[Table 4] shows that the most significant risk factors for infertility among the studied group was postcoital bleeding [P = 0.017, odds ratio (OR)=18.893), followed by irregular menstruation (P = 0.001, OR = 7.193) and a history of appendectomy (P < 0.001, OR = 5.821). However, physical activity seemed to be a protective factor against infertility (P < 0.001, OR = 0.230).{Table 4}


In the current study the total prevalence of infertility was 25%. This result agreed with Vahidi et al. [9], which showed that the prevalence of infertility was 24.9% in Iran. Kumar [10] showed that the prevalence of infertility was 14.2% in an Indian survey. Zegers-Hochschild et al. [11] showed that 15.6% of the women were infertile in Canada. Another study by Meng et al. [12] showed that the prevalence of infertility was 14.2% in China The variation in prevalence rates is most probably attributable to the differences in diagnostic criteria and prevalence of risk factors and the method of assessment.

The infertile group showed a higher BMI. Obesity is a risk factor for infertility as shown by many authors Basyoni et al. [13], Zain and Norman [14], Adesiyun [15], and Esmaeilzadeh et al. [16]. Another study by Sabounchi et al. [17], showed that the obese women who lose weight prior to pregnancy have improved reproductive outcomes. Boots and Stephenson [18], showed miscarriage rate of 10.7% in women with a normal BMI which was significantly lower than that of in obese women (13.6%).

In this study there was significant difference between fertile and infertile group regarding caffeine intake as more than half of women with no caffeine intake were among fertile group. Romero et al. [19] and Chavarro et al. [20] in their study on women trying to conceive did not find that caffeine intake impaired ovulation to the point of decreasing fertility.

More than 60% of infertile group were exposed to passive smoking. Amirkhani et al. [21], study in Tehran found exposure to passive smoking increase the risk of infertility. While disagreed with Romero et al. [19], in Spain which found active smoking and passive smoking to be insignificant asa risk factor for infertility.

In the present study, there was a highly significant difference between fertile and infertile group regarding lifestyle as the majority of infertile women had sedentary life. El-Nasr and Eraky [22], in Cairo showed that the majority of women did not practicing exercise that significantly related with secondary infertility. Also, agreed with Homan et al. [23], in Australia which reported exercise to have a positive impact on fertility.

This study found a significant association between infertility and irregular menstruation. Shamila and Sasikala [24], showed a positive correlation between infertility and menstrual irregularity in South Indian. Also, Mokhtar et al. [25], in Alexandria and Hassan [26], in northern Upper Egypt showed the females with menstrual irregularity had a significantly higher risk of infertility relative to females with regular cycles. While disagreed with Xiaoli et al. [27], in China showed no association between infertility and menstrual irregularity.

About 66.7% of infertile women had history of bacterial vaginosis. This result agreed with Ghiasi et al. [28], who reported in their study that 70.34% of infertile women had bacterial vaginosis.

This study found a significant association between infertility and PID (OR = 5.638). He et al. [29], reported that the risk factors of infertility would include PIDs (OR = 7.078) in India.

Also, found a significant association between infertility and history of appendectomy (P < 0.001). While Elraiyah et al. [30], showed previous appendectomy is not associated with increased incidence of infertility in women.

The current study showed history of ectopic pregnancy was higher among secondary infertile group. Torres-Sánchez et al. [31], showed statistical significant association between both groups regarding ectopic pregnancy. Also, Kelly-Weeder and Cox [32], showed that history of an ectopic pregnancy was an important factor associated with infertility.

This study shows about 26.6% of women who had history of abortion were among the secondary infertility group. Alijotas- Reig and Garrido-Gimenez [33], showed the abortion is estimated to be between 15 and 20% in secondary infertile group. Stanton et al. [34], reported that abortion is a very important cause of secondary infertility.

In the present study, there was no statistically significant difference regarding history of cesarean section between fertile and secondary infertile group. Collin et al. [35], showed no association between mode of delivery and secondary infertility in sub-Saharan Africa. In addition, the fertile group has cesarean section more than infertile group.

This study showed history of dilatation and curettage significantly was more frequent among infertile group secondary. While Momtaz et al. [36], reported no association between two groups. This difference probably was attributed to differences in sample characteristics.


In conclusion, the prevalence of infertility among the studied group was 25%. The prevalence of primary and secondary infertility was 9 and 16%, respectively, among the studied participants.

Presence of infertility increases with some risk factors such as passive smoking, large BMI, physical inactivity, irregular menstruation, history of PID, and history of appendectomy.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Turchi P. Clinical management of male infertility: Prevalence, definition, and classification of infertility. America: Springer; 2015; 5–11.
2World Health Organization. Sexual and reproductive health. 2017. Available from: [Last Accessed on 2017 Aug 24].
3Ardekani A, Chaharsoughi S. Infertility and stress. Int J Fertil Steril 2010; 4(Suppl 1):48.
4Inhorn MC, Patrizio P. Infertility around the globe: new thinking on gender, reproductive technologies and global movements in the 21st century. Hum Reprod Update 2015; 21:411–26.
5National Collaborating Centre for Women's and Children's Health. Fertility: assessment and treatment for people with fertility problems. London, United Kingdom: National Institute for Health and Clinical Excellence (NICE); 2013. 1–63.
6Sharma R, Biedenharn KR, Fedor JM, Agarwal A. Lifestyle factors and reproductive health: taking control of your fertility. Reprod Biol Endocrinol 2013; 11:66.
7Gurunath S, Pandian Z, Anderson RA, Bhattacharya S. Defining infertility-a systematic review of prevalence studies. Hum Reprod Update 2011; 17:575–588.
8Sallam H. Infertility in Egypt: science, myth, and religion, Fall 2013, Infertility awareness association of Canada. Available from: [Last accessed on 2017 Feb 15].
9Vahidi S, Ardalan A, Mohammad K. Prevalence of primary infertility in the Islamic Republic of Iran in 2004–2005. Asia Pac J Public Health 2009; 21:287–293.
10Kumar D. Prevalence of female infertility and its socio-economic factors in tribal communities of Central India. Rural Remote Health 2007; 7:456.
11Zegers-Hochschild F, Adamson GD, de Mouzon J, Ishihara O, Mansour R, Nygren K, et al. International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) revised glossary of ART terminology, 2009. Fertil Steril 2009; 92:1520–1524.
12Meng Q, Ren A, Zhang L, Liu J, Li Z, Yang Y, et al. Incidence of infertility and risk factors of impaired fecundity among newly married couples in a Chinese population. Reprod Biomed Online 2015; 30:92–100.
13Basyoni N, Algamal A, Bakr I, Abdo S. Epidemiology and health related quality of life in infertile females. Egypt J Comm Med 2015; 33:31–47.
14Zain MM, Norman RJ. Impact of obesity on female fertility and fertility treatment. Womens Health (Lond) 2008; 4:183–194.
15Adesiyun AG. Consequences of increasing obesity burden on infertility treatment in the developing countries. Ann Afr Med 2012; 11:247–249.
16Esmaeilzadeh S, Delavar MA, Basirat Z, Shafi H. Physical activity and body mass index among women who have experienced infertility. Arch Med Sci 2013; 9:499–505.
17Sabounchi NS, Hovmand PS, Osgood ND, Dyck RF, Jungheim ES. A novel system dynamics model of female obesity and fertility. Am J Public Health 2014; 104:1240–1246.
18Boots C, Stephenson MD. Does obesity increase the risk of miscarriage in spontaneous conception: a systematic review. Semin Reprod Med 2011; 29:507–513.
19Romero RR, Romero GG, Abortes MI, Medina SH. Risk factors associated to female infertility. Gynecol Obstetr Mexico 2008; 76:717–721.
20Chavarro JE, Rich-Edwards JW, Rosner BA, Willett WC. Caffeinated and alcoholic beverage intake in relation to ovulatory disorder infertility. Epidemiology 2009; 20:374–381.
21Amirkhani J, Yadollah-Damavandi S, Mirlohi SM, Nasiri SM, Parsa Y, Gharehbeglou M. Correlation between abortion and infertility among nonsmoking women with a history of passive smoking in childhood and adolescence. Int J Reprod Med 2014; 2014:678530.
22El-Nasr EM, Eraky EM. Risk factors of secondary infertility among women attending outpatient clinic at Cairo University Hospital; suggested guideline. World J Nurs Sci 2016; 2:01–10.
23Homan GF, Davies M, Norman R. The impact of lifestyle factors on reproductive performance in the general population and those undergoing infertility treatment: a review. Hum Reprod Update 2007; 13:209–223.
24Shamila S, Sasikala S. Primary report on the risk factors affecting female infertility in South Indian districts of Tamil Nadu and Kerala. Indian J Comm Med 2011; 36:59–61.
25Mokhtar S, Hassan HA, Mahdy N, Elkhwsky FE, Shehata GS. Risk factors for primary and secondary female infertility in Alexandria: a hospital based case control study. J Med Res Inst 2006; 27:255–261.
26Hassan HE. Infertility profile, psychological ramifications and reproductive tract infection among infertile women, in northern Upper Egypt. J Nurs Educ Pract 2016; 6:92–108.
27Xiaoli S, Mei L, Junjun B, Shu D, Zhaolian Wand Jin W. Assessing the quality of life of infertile Chinese women: a cross-sectional study. Taiwan J Obstetr Gynecol 2016; 55:244–250.
28Ghiasi M, Fazaeli H, Kalhor N, Sheykh-Hasan M, Tabatabaei-Qomi R. Assessing the prevalence of bacterial vaginosis among infertile women of Qom city. Iran J Microbiol 2014; 6:404–408.
29He X, Hou Q, Jiang HY, Huang HL. A case-control study on the risk factors of female infertility. Zhonghua Liu Xing Bing XueZaZhi 2009; 30:352–355.
30Elraiyah T, Hashim Y, Elamin M, Erwin PJ, Zarroug AE. The effect of appendectomy in future tubal infertility and ectopic pregnancy: a systematic review and meta-analysis. J Surg Res 2014; 192:368–374.
31Torres-Sánchez L, López-Carrillo L, Espinoza H, Langer A. Isinduced abortion a contributing factor to tubal infertility in Mexico? Evidence from a case–control study. BJOG 2004; 111:1254–1260.
32Kelly-Weeder S, Cox CL. The impact of lifestyle risk factors on female infertility. Women Health 2006; 44:1–23.
33Alijotas-Reig J, Garrido-Gimenez C. Current concepts and new trends in diagnosis and management of recurrent miscarriage. Obstet Gynecol Surv 2013; 68:445–466.
34Stanton C, Blanc AK, Croft T, Choi Y. Skilled care at birth in the developing world: Progress to date and strategies for expanding coverage. J Biosoc Sci 2007; 39:109–120.
35Collin SM, Marshall T, Filippi V. Caesarean section and subsequent fertility in sub-Saharan Africa. BJOG 2006; 113:276–283.
36Momtaz H, Flora MS, Shirin S. Factors associated with secondary infertility. Ibrahim Med Coll J 2011; 5:17–21.