1

Chapter 1

Acknowledgment

2
First of all we would like to thank our HOD of community medicine, Dr Shatha Al
Sharbathi and our mentor Dr.Rizwana Shaikh, the community medicine assistant
professor in GMU, who spared no effort to help us.

At the very onset, we would like to convey our sincere appreciation to Dr. Khudsia
Begum (Doha Qatar) and Dr.Saad Aswad, (HOD of the OB/GYN department in Tawam
hospital, Al-Ain) for their endless help and support, without whose help, this research
would not have been possible.

We would also like to thank Dr.Fawaz Torab (Al-AIN), Dr.Ashraf Moawad (Sharjah),
Dr.Mawahib Salman, Dr.Lata Iyer, Dr.Zulekha Mohd , Dr.Shanti Fernandes, Dr.Kasturi
Mumigatti (Ajman), and Dr.Bassel Shammoot who helped us to establish this project.

3
 Chapter 2

Dedication

4
We dedicate this project to our parents who have always been there to support us and no
words will be adequate to pay them back for the love and care they are giving us.

We would also like to thank all the staff and the patients for their cooperation.

5
 Chapter 3

Declaration

6
We declare that this Community Medicine Project “ Infertility – Causes, Associations”
report is an original research work conducted and submitted in part fulfillment of their
Community Medicine course in MBBS program.

Ajman

Signature of students:

Date:

7
 Chapter 4

Certificate

8
I, Dr. Shatha Al Sharbatti do herby certify that this Community Project report
“Infertility – Causes, Associations” is a record of bonafide study and research carried
out by “2006m009 Sarhan Mohammad Sadiq, 2006m066 Anas Bernieh, 2006m036
Ohmed Khilji, 2006m024 Sajjad Hussain “ under my supervision and guidance

Dr. Shatha Al Sharbatti

Professor and HOD
Community Medicine
Gulf Medical University
Ajman,UAE

Abstract
Chapter 5

Title: Causes of infertility in United Arab Emirates females attending infertility clinics: A
Cross Sectional study
9
Objectives:

To determine the major types of infertility in females attending IVF & Infertility
clinics in the UAE, to determine the major causes of infertility , to compare between
the major causes of primary and secondary infertility, to compare the causes of
infertility between local and non local women diagnosed with infertility, to assess the
factors contributing to infertility , to assess the menstrual disorders associated with
infertility, and to comprehend the investigations done in women with primary and
secondary infertility .
Materials and Methods: Cross-sectional study was done in three hospitals in United Arab
Emirates. Total 200 females diagnosed with infertility aged 18-43 participated in this study

Result: 200 perfomas were given to 3 hospitals in the UAE, 151 perfomas were collected from
Tawam hospital (AL AIN), 13 perfomas were collected from Sharjah and 36 perfomas were
collected from GMCHRC .All subjects were females diagnosed with infertility between the ages
18-43. 91 had primary infertility and 109 had secondary infertility. The mean age of females in
this study is around 30.94.and the mean age of menarche is 12 years .PCOS was indeed
the most common cause of infertility which was 27.0% of the female population who
were diagnosed with infertility, followed closely by male factors which were 26.5%
42.2% of females diagnosed with secondary infertility had previous history of abortions

Conclusions: PCOS is the leading cause of infertility; Positive correlations between types of
Infertility and Abortions, types of Infertility and Body Mass Index were correlated and uterine
transverse length Vs secondary infertility. We found that most of our results correlated with
international studies.

10
 Chapter 6

Table Of Contents

Title Page

1. Acknowledgment

2. Dedication

3. Declaration

4. Certificate

11
5. Abstract

6. Table of content

7. List of figures

8. List of tables

9. List Of Symbols, Abbreviations, and Nomenclature

10. Introduction

11. Objectives

12. Review of literature

13. Materials and method

14. Results

15. Discussion

16. Conclusion

17. References

18. Appendix

12
13
 Chapter 7

List Of figures

14
1. Hospitals

2. Nationalities

3. Study participants UAE VS. expatriates

4. Primary and secondary infertility among U.A.E nationals and expatriates

5. Percentage of females with regular and irregular menstrual cycles

6. Average age at marriage for the females

7. Average menstrual period duration for the females with infertility

8. Percentage of females with primary and secondary infertility

9. Percentages of the different causes of infertility

10. Occupation of the participants

11. Educational status of the participants

12. Employment of the participants

15
 Chapter8

List Of tables

1. Personal history of the study participants

2. Symptoms of the study participants

16
3. Medical disorders of the study participants

4. Obstetric problems of the study participants

5. Gynecological problems of the study participants

6. Crosstab between the type of infertility , age , age at menarche, and age at
marriage

7. Crosstab between type of infertility and uterine, and ovarian factors

Chapter9

17
 List Of Symbols, Abbreviations,
and Nomenclature

-UAE: United Arab Emirates

-GMCHRC: Gulf Medical College Hospital and Research Center

-IVF: In Vitro Fertilization

-PCOS: Poly Cystic Ovary Syndrome

-FSH: Follicle-stimulating hormone

-LH: Luteinizing hormone

- PID: Pelvic inflammatory disease

- PRL: Prolactin

- HSG: Hysterosalpingogram

-SD: Standard Deviation

-WHO: World Health Organization

18
 Chapter10

Introduction

19
 (1)
It is a known fact that infertility affects millions of females across the world . The
objective of the present study is to determine the most common causes of infertility faced
by the women of this region. It is vital to understand this because in order to treat the
underlying causes of infertility we must first understand the most common causes of
infertility faced by women.
From previous researches done in this regard we found that most researches showed
(1)
PCOS as a common cause of female infertility . Obesity is highly prevalent in the
(2)
UAE, particularly among females ; based on that, we formulated the hypothesis that
PCOS is the most common cause of female infertility in the population. The objective of
the present study is to determine the different causes of female infertility, and to find out
if PCOS is the most common one, in UAE females attending IVF and infertility clinics.
Our study will highlight the importance of proper awareness programs about infertility to
young adults.

We think our research would be significant for developing further researches on

Infertility.

Chapter11

20
 Objectives

1. To determine the major types of infertility in females attending IVF & Infertility
clinics in the UAE
2. To determine the major causes of infertility
3. To compare between the major causes of primary and secondary infertility
4. To compare the causes of infertility between local and non local women
diagnosed with infertility
5. To assess the factors contributing to infertility :
a. Lifestyle
b. Medical & Obstetric risk factors

6. To assess the menstrual disorders associated with infertility

7. To comprehend the investigations done in women with primary and secondary
infertility

21
 Chapter 12

Review of literature

22
Definition of infertility

Female infertility, male infertility or a combination of the two affects millions of couples
all over the world.(1)(2) .An estimated 10 percent to 15 percent of couples are classified as
(1)
infertile, which means that they've been trying to get pregnant with frequent,
unprotected intercourse for at least a year with no success(1)(2) . Infertility can also be
(7)
defined as a couple’s inability to produce an offspring . In order to calculate the
prevalence of infertility in women we look at percentage of women of reproductive age
(15-49) at risk of pregnancy (not pregnant, sexually active, non-contraception and non-
lactating) who are reported to be trying for pregnancy for two years or more. (8)

Of all couples classified as infertile, female infertility accounts for about 40 percent to 50
(1)(2)
percent. In 30 percent to 40 percent of infertile couples, the man's sperm count is the
(1)(2)
cause, while the remaining 10 percent to 30 percent either is attributed to both male
and female infertility or is unexplained. (1)

Causes of infertility

The human reproductive process is complex. (1) For pregnancy to occur, every step all the
way from the ovary's release of a mature egg to the fertilization of the egg to the fertilized
egg's implantation and it’s growth in the uterus has to take place just right. (1)

In women, a number of factors can disrupt this process at any stage. Female infertility is
caused by one or more of these factors. (1)

Ovulation disorders

(2)
Ovulation disorders account for infertility in 25 percent of infertile couples. These can
be caused by flaws in the regulation of reproductive hormones by the hypothalamus or
the pituitary gland, or by problems in the ovary itself. An ovulation disorder is when
ovulation occurs infrequently or not at all.

23
• Abnormal FSH and LH secretion. The two hormones responsible for
stimulating ovulation each month — follicle-stimulating hormone (FSH) and
luteinizing hormone (LH) — are produced by the pituitary gland in a specific
pattern during the menstrual cycle. Excess physical or emotional stress or a very
high or very low body weight can disrupt this pattern and affect ovulation. The
(3)
main sign of this problem is irregular or absent periods. Much less commonly,
specific diseases of the pituitary, usually associated with other hormone
deficiencies, may be the cause. (1)(2)
• Polycystic ovary syndrome (PCOS). In PCOS, complex changes occur in the
hypothalamus, pituitary and ovary, resulting in overproduction of male hormones
(androgens), which affects ovulation. PCOS can also be associated with insulin
resistance and obesity. (1)(2)

The definition of the polycystic ovary syndrome has been controversial for a long
time. Rotterdam consensus established precise criteria since two among three set
the definition as follow: anovulation, hyperandrogenism and polycystic ovaries.
The aim of this study is to stress on the particularity of ovarian dystrophy and the
management of the resulting infertility that represents an important rate of
medical counselling of women desiring pregnancy.

METHODS: Literature review.

RESULTS: Management consists in two parts: treating hyperinsulinism and

stimulating ovulation. The "step up low dose" protocol is now taking the place of
the classical "step down" protocol. Ovarian drilling has to be considered in case of
resistance to Citrate of Clomifene. The hyper stimulation syndrome is the
common complication to avoid by a regular following. The "coasting" represents
an interesting alternative in case of an explosive response in order to obtain a
controlled follicular failure.

CONCLUSION: Clinical management of the PCOS has to be organized in regard

to patient's age, history, desire of pregnancy and medical staff experience (6)

24
 • Luteal phase defect. Luteal phase defect happens when the ovary doesn't
(4)
produce enough of the hormone progesterone after ovulation. Progesterone is
vital in preparing the uterine lining for a fertilized egg. (1)(2)
• Premature ovarian failure. This disorder is usually caused by an autoimmune
response, where the female body mistakenly attacks ovarian tissues. It results in
the loss of the eggs in the ovary, as well as in decreased estrogen production. (1)(2)

1) Damage to fallopian tubes

When fallopian tubes become damaged or blocked, they keep sperm from getting
to the egg or close off the passage of the fertilized egg into the uterus. Causes of
fallopian tube damage or blockage can include:

• Inflammation of the fallopian tubes (salpingitis) due to Chlamydia or gonorrhea (1)

• Previous ectopic pregnancy, in which a fertilized egg becomes implanted and
starts to develop in a fallopian tube instead of in the uterus (1)
• Previous surgery in the abdomen or pelvis (1)

2) Endometriosis

Endometriosis occurs when tissue that normally grows in the uterus implants and grows
in other locations. This extra tissue growth — and the surgical removal of it — can cause
scarring, which impairs fertility. Researchers think that the excess tissue may also
produce substances that interfere with conception. (2)

25
 3) Cervical narrowing or blockage

Also called cervical stenosis, this can be caused by an inherited malformation or damage
to the cervix. The result is that the cervix can't produce the best type of mucus for sperm
mobility and fertilization. In addition, the cervical opening may be closed, preventing any
sperm from reaching the egg (1) .

4) Uterine causes

Benign polyps or tumors (fibroids or myomas) in the uterus, common in women in their
(1)
30s, can impair fertility by blocking the fallopian tubes or by disrupting implantation.
However, many women who have fibroids can become pregnant. Scarring within the
uterus also can disrupt implantation, and some women born with uterine abnormalities,
such as an abnormally shaped (bicornate) uterus, can have problems becoming or
remaining pregnant. (2)

5) Unexplained infertility

In some instances, a cause for infertility is never found. It's possible that a combination of
several minor factors in both partners underlie these unexplained fertility problems. The
good news is that couples with unexplained infertility have the highest rates of
spontaneous pregnancy of all infertile couples. (1) (2)

One of the studies we found examined the epidemiology and causes of infertility in
Tomsk, Western Siberia, using methodological approaches recommended by WHO and
was based on the findings for a randomly selected sample of 2000 married women aged
18-45 years. Among the respondents, 333 couples were considered infertile since they
26
had not conceived after 12 months or more of unprotected intercourse. This group of
infertile couples was offered comprehensive clinical investigations but only 186 couples
completed them. The infertility rate in Tomsk was 16.7%, being caused by diseases of the
female reproduction system in 52.7% of the couples and by male reproductive diseases in
6.4%. In 38.7% of couples, both spouses suffered from infertility, while in 2.2% of cases
the cause of infertility was not determined. Among the causes of female infertility,
secondary infertility dominated (12.9% of all the women questioned), while primary
infertility affected 3.8% of the women. The most frequent causes of female infertility
were disturbances to tubal patency (36.5%) and pelvic adhesions (23.6%). Endocrine
pathology was found in 32.8% of cases. The most frequent cause of male infertility was
inflammatory disease of male accessory glands (12.9%). In 8.6% of cases infection
resulted in obstructive azoospermia. Varicocele was registered in 11.3% of cases, and
idiopathic pathospermia in 20.9%. Inflammatory complications among females were 4.2
times more frequent than among males.

PIP: In the first study to investigate the reproductive function of the couple at the
population level in the Russian Federation, methodological approaches recommended by
the World Health Organization (WHO) were used to analyze the causes of infertility in
Western Siberia. In the first stage, interviews were conducted with 2000 randomly
selected married women from the city of Tomsk. A total of 333 couples (16.7%) were
considered infertile since they had not conceived after 12 months or more of unprotected
intercourse. 3.8% of couples suffered from primary infertility and 12.9% from secondary
infertility; 24.1% of women in the latter group had experienced complications associated
with birth or abortion. Rigorous clinical investigation of 168 couples identified causes of
infertility in both partners in 38.7%, in the female partner only in 52.7%, and in the male
partner only in 6.4%. More than one cause was present in 80 women (43%). The most
frequent causes of female infertility were disturbances to tubal patency (36.5%) and
pelvic adhesions (23.6%). Endocrine pathology was found in 32.8% of cases. In men, the
most frequent causes were idiopathic infertility or pathospermia (20.9%) and varicocele
(11.3%). Inflammatory complications were 4.2 times more frequent among women than

27
men. The 16.7% frequency of infertility in Western Siberia exceeds the 15% critical level
defined by WHO (8)

Risk Factors for infertility

1) Overweight. Being overweight and having a sedentary lifestyle are possible

causes. Many times obesity is associated with polycystic ovarian syndrome
(PCOS). (1)
2) Underweight. Women with anorexia, bulimia or the ones who follow a strict diet
low in calories are at risk of infertility. Vegetarians also may have an infertility
problem caused by the absence of zinc, vitamin B-12, folic acid and iron from
their alimentation. (2)
3) Alcohol use. Women shouldn’t drink alcohol during conception or pregnancy.
Alcohol consumed in moderate quantities doesn’t affect male fertility. (1)
4) Smoking. Both women and men reduce the chances of conceiving if they are
smokers. In addition to this miscarriages occur more often in women who smoke.
The sperm of men who smoke has a lower quality than those of nonsmokers.
Smoking marijuana also affects fertility. (1)
5) Caffeine. Studies show that an increased amount of caffeine may decrease
fertility, especially in women. The risk of a miscarriage is higher in women who
consume caffeine excessively. Caffeine can be found not only in coffee, it also
found in tea, chocolate, some medications and soft drinks. (1)
6) Exercise. Too much exercise (more than 7 hours a week) can cause ovulation
problems. Exercises that are too exhausting can affect IVF treatment. But
insufficient exercise can cause obesity and that is another risk of infertility. (2)
7) Age. After the age of 32 a woman’s fertility decreases. The older the woman is,
the lower her chances of fertility are. The eggs of older women are disposed to
chromosomal abnormalities. In addition to this, older women may have other
health problems that could stand in the way of conceiving. (1)
8) Vaginal douching can cause gynecological problems that may affect fertility.
Vaginal douching may cause infection, preterm birth, pelvic inflammatory disease
(PID). (2)
28
 9) Sexual practices like having multiple partners without using a condom or having
intercourse during menstruation increases the risk of transmitting organisms that
may cause pelvic inflammatory disease causing infertility. (1)
10) Stress. The hypothalamus gland controls the reproductive hormones as well as
the stress hormones. A high level of stress hormones can stop the menstruation. It
is still unknown if the stress affects fertility, but is proven the fact that it affects
the result of fertility treatments. (2)
11)Other Factors Several plastic chemicals adversely affect reproductive ability.
This study examined the possible association between employment in the plastics
industry and infertility. Dynamic cohorts of economically active women and men
were followed for hospital contacts due to infertility in the Danish Occupational
Hospitalization Register, from 1995 to 2005. A person was considered to be at
increased risk in a particular year if plastic work was the main occupation in the
previous year. Analyses were standardized according to county, socio-economic
group, year and age. 107 cases of treatment for female infertility were observed
among female plastic workers, as opposed to an expected 87.15 cases, i.e. relative
risk was 1.23 (95% CI: 1.01-1.48). For male workers the numbers were 41
respectively 49.9 cases, with relative risk being 0.82 (95% CI: 0.59-1.11). The
increased incidence of infertility treatment in female plastics workers motivates
more specific studies of reproductive occupational health in the plastics industry
(7)

Previous research has highlighted a lack of fertility awareness in the general population
especially in relation to the optimal fertile period during the menstrual cycle, incidence of
infertility and duration of the reproductive life span. The current study assessed fertility
knowledge more broadly in young people and investigated three areas of knowledge,
namely risk factors associated with female infertility (e.g. smoking), beliefs in false
fertility myths (e.g. benefits of rural living) and beliefs in the illusory benefits of healthy
habits (e.g. exercising regularly) on female fertility.

METHOD

29
The sample (n = 149) consisted of 110 female and 39 male postgraduate and
undergraduate university students (average age 24.01, SD = 7.81). Knowledge scores
were based on a simple task requiring the participants to estimate the effect a factor
would have on a group of 100 women trying to get pregnant. Items (n = 21) were
grouped according to three categories: risk factors (e.g. smoking; 7 items), myths (e.g.
living in countryside; 7 items) and healthy habits (e.g. being normal weight; 7 items).

RESULTS

An analysis of variance showed a significant main effect of factor ( P < 0.001) and post
hoc tests revealed that young people were significantly better at correctly identifying the
effects of risks compared with null effects of healthy habits ( P < 0.001) or fertility myths
( P < 0.001).

CONCLUSION

Young people are aware that the negative lifestyle factors reduce fertility but falsely
believe in fertility myths and the benefits of healthy habits. We suggest that the public
education campaigns should be directed to erroneous beliefs about pseudo protective
factors (9)

Investigations done to find cause of infertility

A full history should be taken and examination performed. The following are
particularly relevant: (3)

• Mid-luteal progesterone level to assess ovulation.

o If low it may need repeating as ovulation does not occur every month. (1)
o The blood test is taken 7 days before the anticipated period, that is on day
21 of a 28 days cycle but this day will need to be adjusted for different
lengths of cycle. (1)
• Basal body temperature charts are not recommended as they are unreliable(1)
• FSH and LH should be measured, especially if there is menstrual irregularity.
30
 o High levels may suggest poor ovarian function.
o A comparatively high LH relative to FSH is typical of polycystic ovary
disease.
• Clinical Knowledge Summaries advise that thyroid function tests should only be
undertaken if there are grounds for suspicion as infertile women are no more
likely to have thyroid disease than the rest of the population.(1)
• Similarly, prolactin (PRL) should only be measured where there is clinical
suspicion.
• Chlamydia screening is recommended.
o Not only may it be a cause of infertility but instrumentation of the genital
tract in subsequent investigations may produce PID. (2)

Tubal patency

Tubal damage is estimated to account for 14% of infertility in women. (1)If the test has not
been performed in primary care, a test for Chlamydia will be performed before using
instruments that may induce a Chlamydia salpingitis.

• A hysterosalpingogram (HSG) is recommended by NICE for women who are

not known to have had pelvic inflammatory disease, ectopic pregnancy or
endometriosis. The test is reliable and less invasive than laparoscopy. This test is
more useful than laparoscopy at demonstrating the cavity of the uterus that may
be distorted by fibroids or septate. However, this test merely demonstrates the
patency of one or both tubes whilst what really matters is the function of fine cilia
within the tubes.
o The procedure does not require general anaesthesia although some
sedation may be used as it can be uncomfortable.
o With the patient in the lithotomy position a Vulsellum forceps is attached
to the cervix and the tip of a syringe is pushed into the cervix.
o A radio-opaque medium is injected and the picture viewed on x-ray
screening.

31
 o If there is no occlusion then little pressure should be required to inject the
contrast material and screening should show free spill of medium from
both tubes.
o If it is available, hystero-salpingo-contrast-ultrasonography may be used.
• Laparoscopy is recommended by NICE if there are known problem such as PID,
endometriosis or previous ectopic pregnancy. (5)
o Laparoscopy is usually performed under general anaesthetic.
o The abdomen in insufflated with carbon dioxide and a trocar is inserted
through an incision in the lower curve of the umbilicus. (1)
o Under direct vision a smaller trocar is inserted through the lower abdomen
and this allows forceps to be introduced to move the pelvic organs to
inspect them.
o Simple inspection is the first task. The surgeon checks if the pelvic organs
look normal. He looks for endometriosis and sign of inflammation and
adhesions. Do the ovaries look normal and active or is there the shiny
sclerocystic appearance of polycystic ovary disease? The pelvic organs
should be freely mobile. (10)
o Another operator injects a blue dye into the cervix and he sees if there is
free spill of dye from both fallopian tubes.
o Through the lower abdominal portal it is possible to introduce scissors or
diathermy to cut any minor adhesions that may be found.

In a study of 256 infertile women who underwent tubal patency tests by

laparoscopy and dye, the tubes were classified as normal, patent with macroscopic
tubal adhesions, patent with one tortuosity, and patent with multiple tortuosities. (1)
Only in the last group did the procedure seem to have any effect on outcome with
66% pregnant within a year and 81% pregnant within 2 years.(1)

• Post coital tests: NICE recommend that the test has no predictive value and so
should not be offered. (4)

32
The table below shows some of the possible pathologies of infertility

Feature Possible pathology

Oligo /amenorrhea Ovulatory disorder
Pelvic infection Tubal disease
STD Tubal disease
Pelvic surgery Tubal disease
Appendicitis Tubal disease
Galactorrhea Ovulatory disorder
Postpartum infection Tubal disease
Smoking Possible ovulatory
Cervical surgery Cervical cause
Advanced age Ovulatory disorder
Pelvic pain Endometriosis
Sexual dysfunction Coital problems

Solutions for infertility

• Laparoscopy. Women who have been diagnosed with tubal or pelvic disease can
either undergo surgery to reconstruct the reproductive organs or try to conceive
through in vitro fertilization (IVF, see below). Using a laparoscope inserted
through a cut near the bellybutton, scar tissue can be removed, endometriosis
treated, ovarian cysts removed, and blocked tubes opened. A hysteroscope placed
into the uterus through the cervix can be used to remove polyps and fibroid
tumors, divide scar tissue, and open blocked tubes. (3)
• Medical therapy. Women suffering from ovulation problems may be prescribed
medications such as clompiphene citrate (Clomid, Serophene) or gonadotropins
such as Gonal F, Follistim, Humegon and Pregnyl, which can lead to ovulation.
Gonadotropins can induce ovulation when Clomid or Serophene do not work.
These medications also can enhance fertility by causing multiple eggs to ovulate
during the cycle (normally, only one egg is released each month). Gonadotropin
therapy may be offered for unexplained infertility or when other factors have been
33
 corrected without resulting in pregnancy. Metformin (glucophage) is another type
of medication that may restore or normalize ovulation in women who have insulin
resistance and/or PCOS (polycystic ovarian syndrome). (3)
• Intrauterine insemination. Intrauterine insemination refers to an office
procedure in which semen is collected, rinsed with a special solution, and then
placed into the uterus at the time of ovulation. The sperm are deposited into the
uterus through a slender plastic catheter that is inserted through the cervix. This
procedure can be done in combination with the previously listed medications that
stimulate ovulation. (1)
• In vitro fertilization. In vitro fertilization refers to a procedure in which oocytes
(egg cells) are fertilized in a culture dish and placed into the uterus. The woman
takes gonadotropins to stimulate multiple oocyte development. When monitoring
indicates that the oocytes are mature, the oocytes are collected using a vaginal
ultrasound probe with a needle guide. The sperm are collected, washed, and added
to the oocytes in a culture dish. Several days later, approximately 3 embryos
(fertilized oocytes) are returned to the uterus using an intrauterine insemination
catheter. Any extra embryos can be cryo-preserved (frozen) for later use, upon the
consent of the couple. (1)
• Oocyte donation.Oocyte donation helps women who do not have normally
functioning ovaries (but who have a normal uterus) to achieve pregnancy. Oocyte
donation involves the removal of oocytes from the ovary of a donor who has
undergone ovarian stimulation with the use of fertility drugs. The donor's oocytes
are then placed together with the sperm from the recipient's husband for in vitro
fertilization. The resulting fertilized oocytes (embryos) are transferred to the
recipient's uterus. (1)

Medical therapy and in vitro fertilization can increase the chance of pregnancy in women
diagnosed with unexplained infertility. (5)

34
 Chapter 13

Materials and Methods

Study design: Cross-sectional study

Subjects: Our study included a few hospitals in the UAE, our study population being
females in the UAE.

A) Inclusion criteria: Infertile females

Exclusion criteria: None

B) Sample design: Non-probability consecutive sampling

C) Sample size: around 200

The sample size can be calculated by using the formula:

35
n = (1.96)2pq/L2,

Where "p" = proportion of infertility (assume 2%)

"Q" = 1-p and

"L" = allowable error 0.5 (if allowable error is 0.05) sample size will increase further

Sample size is estimated sample size:

n= 3012
Ours is undergraduate project, it is treated as a pilot test to conduct further studies hence
it was decided we collect data from about 200 women

Variables:

A) Predictor (independent): Infertility maybe influenced by the following factors:

Age, Obesity, Diabetes, Hypertension , Pelvic Inflammatory Disease ,

Endometriosis, Polycystic Ovaries, Anatomical Defect, hypothyroidism,
hyperprolactemia, Tubal Block, Multiple Fibroids

B) Outcome (dependent): Number of cases of Infertility

Tool for data collection: Questionnaire

A) Type: Close- ended questions along with some Open ended ones

B) Preparation: The questionnaire was prepared based on extensive reading of literature

on the subject.

C) Validity: We consulted a panel of experts in this field who helped us in preparing the
questionnaire. This ensured that our questionnaire was valid.

Pilot study: Was done in the OBG department in Gulf Medical Hospital Ajman

Data collection Method: Questionnaire to Infertility Clinics and collection

36
Time plan:

Our topic was finalized and registered with the Department of Community Medicine on
the 4th of April, 2009. On the 6th of April, and the objectives of the study was determined.
We developed the study protocol and submitted it on the 20th of April. We then finalized
the tool for data collection and submitted the review of literature. We finished our data
collection on the 31st of December. Analysis and submission of the project was done on
the 30th of January. Our project was presented in the month of February.

Limitations:

We could not include all the hospitals in the UAE due to time constraints and restricted
ourselves to 3 hospitals in the UAE.

Ethical issues:

The privacy of the participants of this study was protected as they were not asked for
their names. This study complies with the principles of the Helsinki declaration.

Analytical approach:

1. Data will be entered to excel

2. Data will be analyzed using PASW-statistics 18 (SPSS) program
3. Data will be presented in percentages (as tables and graphs)
4. The chi-square test will be used for associations
5. The Z-test will be used for proportions

37
Chapter 14

Results

38
39
40
This Figure shows the hospitals from where data was collected. As can be
seen most of the data was collected from Twam Hospital in Al Ain which
gets referred cases of infertility from all over U.A.E

This Figure shows the nationalities of the study participants. As can be noted
most of the participants where U.A.E nationals. It is important to note that
this is because most of our data was collected from Twam Hospital which
has a patient population that primarily consists of U.A.E nationals

41
42
43
This Table shows the demographic data of the study participants. An
important point to note is that the average BMI of the study participants is
29.14 + 6.84 which is considered obese for females.

This Figure shows the age at marriage for the study participants

44
45
This Figure shows the menstrual period duration of the study
participants. The mean is 6.30 + 4.99

This Figure illustrates the age of menarche of the study participants. The
participants have been divided into primary and secondary infertility.

46
47
This Figure shows the educational status of the study participants. As is
illustrated in the figure the vast majority of the study participants had either
a university or a secondary educational background.

48
This Figure shows the employment of the study participants. The majority of
the study participants were unemployed. This probably indicates that they
where house wives.

49
50
51
This Figure shows the occupation of the study participants. As can be seen
in the figure the majority of the study participants were housewifes.

This Figure shows the nationalities of the study participants. The figure is
divided into study participants that are U.A.E nationals and expatriates.

52
53
54
This Figure shows the type of infertility among U.A.E nationals vs.
expatriates. As can be seen in the figure secondary infertility is apparently
much more common among U.A.E nationals when compared to expatriates.

55
The Figure shows the regularity of menstrual cycles among females with
infertility. As is demonstrated by the figure the vast majority of females have
regular menstrual duration.

56
57
The Figure shows the regularity of type of infertility among the study
participants. As is demonstrated the majority of females that presented to
infertility clinics had secondary infertility.

58
The Figure shows the regularity of causes of infertility among the study
participants. As is demonstrated in the figure the majority of the females had
PCOS as the diagnosed cause of infertility. This was closely followed by
male factors as the leading cause of infertility among couples in the U.A.E

59
60
61
This Table shows the personal history of the study participants. As is
demonstrated in the table only 1% of the females drank alcohol and only
2.5% of the females smoked. The cause for this could be because of the
cultural background or because the females are trying to conceive so they
have temporarily stopped these personal habits.

This Table shows the symptoms of the study participants. As is

demonstrated dysmenorrhea is quite prevalent among the study population.

62
63
64
This Table shows the medical disorders of the study participants.

This Table shows the obstetric problems of the study participants.

65
66
This Table shows the gynecological problems of the study participants.

67
This Table shows a crosstab between the type of infertility and the age, age
at marriage, and the age of menarche of the study participants.

68
69
70
This Table shows a crosstab between the type of infertility and the
symptoms experienced by the study participants

This Table shows a crosstab between the type of infertility and the personal
habits of the study participants

71
72
This Table shows a crosstab between the type of infertility and the medical
disorders of the study participants

73
This Table shows a crosstab between the type of infertility and the obstetric
problems of the study participants

74
75
This Table shows a crosstab between the type of infertility and the
gynecological problems of the study participants

76
This Table shows a crosstab between the type of infertility and the
investigations done by the study participants

77
78
This Table shows a crosstab between the type of infertility and the surgical
history of the study participants

This Table shows a crosstab between the type of infertility and the BMI,
uterine and the ovarian factors of the study participants. As can be seen in
this crosstab There is a strong correlation between secondary infertility and a
high BMI. There is also a correlation between secondary infertility and
Uterine Transverse Length and Right Ovarian Width.

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 Chapter 15

Discussion

80
Data was collected from 200 records. 91 had primary infertility and 109 had secondary
infertility

After data analysis we found out that the main cause of Infertility is indeed Polycystic
Ovarian disease. The second leading cause being male factors.The mean age of females
for females diagnosed with infertility was around 30.94(31) years. .Previous studies have
shown that female fertility decreases with advancing age(Spira,1988;Maroulis,1991).Also
it has been documented that one third of females who defer pregnancy until their late
thirties and over half of females above the age of 40 will have problems conceiving(Virro
and Shewuck,1984;Alrayyes et al.,1997).

Also an 8 year research by some researchers have said that young age does not protect
against reduced ovarian reserve, hence probably contributing to the infertility among
young females. (12)

The mean age of menarche among UAE females diagnosed with infertility is
approximately 12 years. Research shows us that young age at menarche was significantly
associated with strong indicators of diminished ovarian reserve hence contributing to
infertility. Uterus didelphys with obstructed hemivagina and ipsilateral renal agenesis is a
rare and specific entity referred to as Herlyn-Werner-Wunderlich syndrome. It usually
presents after menarche with remittent pelvic pain and a palpable pelvic mass due to
hematocolpos. The maximum amount of females diagnosed with infertility were married
at 25 years of age . The ages of females diagnosed with infertility ranged from 11 years
at marriage to 40 years at marriage. (11)

We did a comparative study between UAE females diagnosed with infertility and other
nationals. The maximum number of females diagnosed with infertility were housewives ,
the second most prevalent group were the working class and the remainder were students.

Our comparative study revealed that PCOS was indeed the most common cause of
infertility which was 27.0% of the female population who were diagnosed with infertility,
followed closely by male factors which were 26.5% .The remainder of the causes in order
of prevalence were Unknown,Ovulation,Tubal block,Uterine pathology,others and
endometriosis. New researches show us that Metformin can be used to treat PCOS.
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Hence the need of metformin would significantly reduce the number of PCOS cases and
thereby reducing infertility.(17)(14)

Most of the females diagnosed with infertility had completed university, next to that the
females had only completed secondary education. The remaining had completed high
school, primary school or had no formal education. Most of the females diagnosed with
infertility were unemployed and the remainder worked either full or half time jobs. Some
of the females diagnosed with infertility had irregular menstrual cycles which probably
was the reason for the infertility. An exploratory recent study had suggested that there
might be an associated risk between females who have worked as a flight attendant,
service station attendant, or health worker, particularly a nurse and endometriosis. (13)

We did not find any correlation between females diagnosed with infertility and primary
and secondary infertility. There were more females with secondary infertility than
primary infertility.

The husbands of the females diagnosed with infertility had abnormal semen count which
must be the male factor involved in the infertility study. On referencing previous studies
we came across an interesting article which said that Infection by CagA-Positive
Helicobacter pylori Strains may Contribute to Alter the Sperm Quality of Men with
Fertility Disorders and Increase the Systemic Levels of TNF-[alpha]. (16)Also another
research we found was a research showing the association between diabetes and male
fertility which might have been the reason for the abnormal cases of abnormal semen
analysis. (15) For the treatment of male factors the main solution seemed to be IVF and
ICSI.

We found out that there is indeed a positive correlation between types of Infertility and
Abortions.42.2% of females diagnosed with secondary infertility had previous history of
abortions. .We also found types of Infertility and Body Mass Index were correlated. We
have noticed that as there is an increase in BMI, it leads to secondary infertility. On
checking the uterine transverse length Vs secondary infertility we found there was
definitely a positive correlation.

82
 Chapter16

Conclusion

83
Our research revealed that the majority of cases in our study had secondary

infertility.The main causes included PCOS,male factor and tubal blockage.We

noticed that most of the causes were equally prevalent in both primary and secondary
infertility.There were more cases of secondary infertility among UAE nationals and
more cases of primary infertility were prevalent among the population outside that of
the UAE.Most of our cases were house-wifes. Minority of our cases had
medical/surgical problems,but what was interesting that 95% of females with
secondary infertility had previous abortions.lifestyle factors contributing to infertility
was Obesity .Medical and obstretic risk factors had no relation with type of
infertility.Menstrual disorders associated with infertility are
.Histosalphingography,Semen analysis,Ultrasound,findings were used to diagnose the
cause of infertility among females diagnosed with primary and secondary infertility.

84
 Chapter 17

References

85
1. mayoclinic.com [Internet].Mayofoundation of medical education and research.;c
June 06, 2009.Available from : www.mayoclinic.com/health/female-
infertility/DS01053

2. accessmedicine.com [Internet].Accessmedine.LLC.;c June

06,2009.Available from : www.accessmedicine.com/content.aspx?
aID=3267283&searchStr=female+infertility

3. Hull MG, Glazener CM ,Kelly NJ : Population study of causes treatment, and

outcome of infertility. Br Med J (Clin Res Ed). 1985 Dec 14; 291(6510):1693-7
Nov;18(4):259-62.
4. webmd.com [Internet].Webmd.LLC.;c June 06,2009.Available from:
www.webmd.com/infertility-and-reproduction/guide/infertility-reproduction-
treatment-care.

5. Tunis Med. 2008 Nov;86(11):963-72 , PMID: 19213486 [PubMed - indexed for

MEDLINE.

86
6. Reprod Toxicol. 2009 Apr;27(2):186-9. Epub 2009 Jan 21 , PMID: 19429396
[PubMed - indexed for MEDLINE.

7. Bull World Health Organs. 1998; 76(2):183-7, PMID: 9648359 [PubMed -

indexed for MEDLINE.

8. proquest.umi.com [Internet].Proquest.LLC.;c June 06,2009.Available from:

proquest.umi.com/pqdweb?
did=1516341501&sid=1&Fmt=2&clientId=46914&RQT=309&VName=PQD.

9. www.who.int [Internet].World health organization.;c June 06, 2009.Available

from: www.who.int/reproductive-health/infertility/26.pdf

10. www.app.who.int [Internet].World health organization.;c June 06, 2009.Available

from: apps.who.int/reproductive indicators/definitionofindicators.asp

11. Human Reproduction Vol.17,No.6 pp. 1519 -1524,jun 2002

12. Human Reproduction Vol.18, No.10pp. 2225-2230,oct 2003
13. Scandinavian Journal of Work, Environment & Health Stockholm: May
2009. Vol. 35, Iss. 3; pg. 233, 8 pgs
14. Human Reproduction Update. Oxford: Jul/Aug 2009. Vol. 15, Iss. 4; pg. 391, 18
15. International Urology and Nephrology. Dordrecht: 2009. Vol. 41, Iss. 4; pg. 777
16. Digestive Diseases and Sciences. New York: Jan 2010. Vol. 55, Iss. 1; pg. 94
17. JAAPA: Journal of the American Academy of Physician
Assistants. Montvale: Apr 2009. Vol. 22, Iss. 4; pg. 49, 2 pgs

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 Chapter 18

Appendix

88