From Department of Public Health Sciences Division of International Health (IHCAR) Karolinska Institutet, Stockholm, Sweden

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

Stockholm 2005

All previously published papers were reproduced with permission from the publisher. Published and printed by Karolinska University Press Box 200, SE-171 77 Stockholm, Sweden © Friday Ebhodaghe Okonofua, 2005 ISBN: 91-7140-355-8

This thesis is dedicated to all Nigerian couples currently grappling with experiences of infertility. It opens an opportunity for the prevention of similar episodes and the use of evidence-based methods of treatment.

ABSTRACT 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