Infertility is a public health problem during the re.
productive age, affecting about 10-15% of couplesattempting to achieve pregnancy in worldwide (
According to World Health Organization (WHO),
the term primary infertility is used when a womanhas never conceived and secondary infertility is theincapability to conceive in a couple who have had atleast one successful conception in the past (
Nevertheless, male infertility is due to hormonal imbalances,
and sperm abnormalities (
This cross-sectional study was conducted with the approval of the Ethic of the Moroccan health authorities in the region of Marrakech-Safi. This region is located in the middle of Morocco and consists of one state and eight administrative provinces. This study was conducted at different public and private health centers in the region of Marrakech-Safi. A sample of 619 infertile women referring to these health centers was selected by a simple random sampling method, between 1 October 2013 and 31 December 2015. The subjects were chosen without any previous appointments.
The study protocol was explained and the informed consent was obtained from all participants before enrolment. In this study, all data was collected through a questionnaire and the information provided by health booklets for each married woman who had difficulty becoming a mother after at least 12 months of regular unprotected sexual intercourse. The questionnaire contained different elements: socio-economic data, demographic characteristics, age of the couple, and their nutritional status. Also, searching health booklets provided history and clinical information [urogenital infections, medical complications, diabetes, thyroidism, menstrual disorders, polycystic ovary syndrome (PCOS), tubal dysfunction, varicocele and congenital uterine anomalies] and methods of diagnosis, particularly the results of ultrasounds, hysterosalpingographies, hysteroscopies, hormone levels and semen analyses.
Other data associated with male and female reproductive organs were included such as menstruation disorders, uterine malformations, hormonal imbalances, varicocele, the quality of sperms, and other medical complications.
The subjects who had met our inclusion criteria were married women during their childbearing ages, who had referred to health centers for infertility problems after 12 months of trying for pregnancy. Prior to this research study, the collection tool was tested with a pilot group of women similar to those wishing to participate voluntarily in this survey. All women were entered into the study and their associated data was collected by trained research nursing students.
A one-sample Kolmogorov-Smirnov test was used to analyze normality for continuous variables. A Chi-square test and Fisher’s exact test were used for categorical variables.
Student’s t test was used to estimate the observed differences between the means. The multivariate data analysis was used to allow for the elimination of the confounding factors and entering the weight of the associated variables with the type of infertility in the bivariate analysis set at 0.2. These variables were used to identify factors that were independently associated with secondary infertility. Associations were measured in odds ratio (OR) with 95% confidence intervals (CI). Data analyses were carried out using SPSS (SPSS Inc. for Windows version 10.0, Chicago). For all analyses the differences were considered significant when P<0.05.
A total of 619 infertile women were included in this study, 417 (67.37%) with primary infertility and 202 (32.63%) with secondary infertility.
Comparison of socio-economic and demographic characteristics between primary and secondary infertilities
|Variables and modalities||Primary infertility n (%) or Mean ± SD||Secondary infertility n (%) orMean ± SD||P value|
|Women’s age (Y)||28.7 ± 5.7||31.95 ± 5.6||0.0001|
|Low||28 (6.70)||26 (12.9)||0.003|
|Average and high||389 (93.3)||176 (87.1)|
|Normal weight||351 (84.2)||172 (85.1)|
|Excess weight||66 (15.80)||30 (14.90)||0.490|
|Duration of marriage|
|>5 Y||145 (34.8)||146 (72.3)|
|≤5 Y||272 (65.2)||56 (27.7)||0.0001|
|Period of infertility|
|≤3.8 Y||269 (64.5)||112 (55.4)|
|>3.8 Y||148 (35.5)||90 (44.6)||0.075|
|Imaging tests (women)|
|Hysterosalpingography (HSG)||163 (39.08)||60 (29,70)||0.023|
|Pelvic ultrasonography||394 (94.48)||182 (90,09)||0.033|
|Hysteroscopy/ laparoscopy||45 (10.8)||15 (7.4)||0.183|
|Biological tests (women)|
|Hormonal tests||177 (42.44)||70 (34.65)||0.063|
|Post-coital test||14 (3.14)||00 (00)||0.008|
|Partner age (Y)||35.8 ± 7.7||38.8 ± 6.8||0.001|
|Partner consultation||239 (57.3)||60 (29.7)||0.001|
|Semen analysis||237 (56.8)||59 (29.2)||0.001|
Comparison of clinical characteristics between primary and secondary infertilities
|Variables and modalities||Primary infertilityn (%)||Secondary infertilityn (%)||P value|
|Menstrual disorders||213 (51.1)||92 (45.5)||0.191|
|Hormone disorder (FSH, LH, AMH)||65 (36.7)||27 (38.6)||0.782|
|Endocrine diseases (diabetes, thyroid)||22 (5.3)||15 (7.4)||0.290|
|Polycystic ovary syndrome||107 (27.2)||53 (29.1)||0.620|
|Obstruction and tubal dysfunction||105 (64.40)||41 (68.30)||0.581|
|Endometriosis||14 (8.6)||8 (13.3)||0.290|
|Uterine synechiae||6 (3.7)||6 (10.0)||0.065|
|Uterine and cervical factors|
|Congenital uterine anomaly||27 (6.9)||15 (8.2)||0.554|
|Fibroids||25 (6.3)||13 (7.1)||0.721|
|Polyps||12 (3.0)||4 (2.2)||0.760|
|Genital infections||65 (15.6)||33 (16.3)||0.810|
|Varicocele||31 (13.00)||4 (6.7)||0.263|
|Abnormal sperm||107 (45.1)||12 (20.3)||0.001|
|Origin of infertility|
|Unexplained infertility||20 (8.33)||07 (11.30)|
|Male infertility||54 (22.5)||04 (6.50)||0.003|
|Female infertility||106 (44.20)||41 (66.10)|
|Mixed infertility||60 (25)||10 (16.10)|
FSH; Follicle stimulating hormone, LH; Luteinizing hormone, and AMH; Anti-mullerian hormone.
Variables independently associated with primary (n=202) and secondary (n=417) infertilities, according to the multiple logistic regression model
|Variables and modalities||β||χ2||P value||OR||95%||CI|
|Duration of marriage: ≥ 5 Y||2.507||8.569||0.003||12.263||2.289||65.685|
|Period of infertility: ≥3, 8 Y||-1.560||3.628||0.057||0.210||0.042||1.046|
OR; Odds ratio and CI; Confidence intervals.
The socio-economic and demographic characteristics between primary and secondary infertilities are presented in Table 1. The average of women’s ages were 28.7 ± 5.7 years and 31.95 ± 5.6 years in primary and secondary infertility, respectively. The average ages of their husbands were 35.8 ± 7.7 years and 38.8 ± 6.8 years in primary and secondary infertility, respectively. The difference between their ages was significant. Also, a good socio-economic situation was reported by primary infertile women (93.3%) compared to those with secondary infertility (P=0.003). After that, the majority of these women reported that their weights were normal and only 15% had excess weight. Furthermore, a longer duration of marriage was reported in secondary infertility compared with primary infertility (P=0.001).
However, the duration of infertility was not different in the two groups of infertility. In comparison to secondary infertility, primary infertile women showed enthusiasm for medical diagnosis such as hysteronsalpingography (39.08%), and pelvic ultrasound (94.48%). However, in secondary infertility, 70.3% of spouses refused to see a specialist compared with the primary infertility group (P=0.001). The semen analysis was mainly practiced to evaluate primary infertility (56.8%) with a significant difference.
The clinical characteristics between the two groups of infertility were presented in Table 2. With the exception of menstrual disorders, the major causes of primary infertility were entirely due to male reproductive organs, particularly varicocele and abnormalities of semen, with a significant difference. The main causes of secondary infertility were observed mostly among women; such causes include hormonal disturbance, medical complications, polycystic ovary syndrome, tubal dysfunction, genital infections, uterine anomalies, endometriosis and adhesions without significant difference. However, according to multiple logistic regression models, variables independently associated with primary and secondary infertility, are presented in Table 3. In this model, the duration of marriage (OR= 12.263: 2.289-65.685), the age of the woman (OR=1.268: 1.038-1.549), and the socio-economic status (OR=3.83: 1.011-14.70) were relatively independent predictive variables associated to secondary infertility.
To our knowledge, this is the first study able to determine
the difference between primary and secondary infertility
in Morocco and to distinguish among the associated
factors. The overall rates of primary and secondary infertility
were 67.37 and 32.63%, respectively. This result is
similar to those published in other areas of Africa (
In this study, this result can be explained partly by a major
change in the age for marriage in Morocco (from 17.3
years old in 1960 to 26.6 years old in 2010) (
In secondary infertility, an overly long duration of marriage
and an advanced age of the couple could decrease
their chances of having a new child. This finding was
close to the one recorded by Keskin et al. (
In primary infertility, the majority of women with relatively
high-to-moderate socio-economic status are able to
resolve their infertility problems. This status can provide
fast and easy access to several diagnostic methods and
infertility treatments (
According to the perception of the participants, however,
their body weights were normal in both primary and
secondary infertility groups. This perception is not compatible
with that observed among Moroccan population
This result can be explained by the advanced age and
also exposure to urogenital infections affecting the quantity
and the quality of sperms. In Africa, the sperm abnormalities
were estimated at 68% for the age 31-40 years
Finally, the difference between primary and secondary infertilities in Morocco was relatively associated with three independent variables, particularly the duration of marriage (OR=12.263: 2.289-65.685, the woman’s age (OR=1.268) and socio-economic position (OR 3.83). Furthermore, the bounds of this interval were very far from the value 1, which means that the result was positive and therefore the duration of infertility was strongly related to secondary infertility.
To reduce the limitations in our study, further investigations should be undertaken with control groups of fertile women to provide additional information on risk factors for male and female infertility. Furthermore, a high-quality dialogue between all participants will be recommended for better management of infertility.
In this study, primary and secondary infertilities were due to the intersection of several demographic characteristics and medical factors. However, woman’s age, duration of marriage and socio-economic status had a significant impact to accentuate the severity of secondary infertility.