Bell Suzanne O, Moreau Caroline, Sarnak Dana, Kibira Simon P S, Anglewicz Philip, Gichangi Peter, McLain Alexander C, Thoma Marie
Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Soins Primaires et Prévention, Centre de recherche en Epidémiologie et Santé des Populations, U1018, Inserm, Villejuif, France.
Hum Reprod. 2024 Dec 1;39(12):2848-2860. doi: 10.1093/humrep/deae218.
Does the prevalence of 12-month infertility in Burkina Faso, Côte d'Ivoire, Kenya, and Uganda differ between women trying to conceive and the broader population of women exposed to unprotected sex, and how are prevalence estimates affected by model assumptions and adjustments?
Estimates of 12-month infertility among tryers ranged from 8% in Burkina Faso to 30% in Côte d'Ivoire, increasing substantially among a larger population of women exposed to unprotected intercourse.
While having a child is a fundamental human experience, the extent to which women and couples experience infertility is a neglected area of research, particularly in sub-Saharan Africa. Existing estimates of infertility in this region vary widely from 2% to 32%, however, potential impacts of variability in study populations and model assumptions have not been well-examined.
STUDY DESIGN, SIZE, DURATION: We used cross-sectional nationally representative survey data from Burkina Faso, Côte d'Ivoire, Kenya, and Uganda. We employed a multi-stage cluster random sampling design with probability proportional to the size selection of clusters within each country to produce representative samples of women aged 15-49. Samples ranged from 3864 in Côte d'Ivoire to 9489 in Kenya.
PARTICIPANTS/MATERIALS, SETTING, METHODS: We created two analytic samples in each country-tryers and a broader sample of women exposed to unprotected sex-exploring differences in population characteristics and estimating the period prevalence of 12-month infertility using the current duration (CD) approach. We also examined the impact of several model assumptions within each of the two analytic samples, including adjustments for recent injectable contraceptive use, unrecognized pregnancy, infertility treatment, underreported contraceptive use, and sexual activity.
Employing the CD approach among tryers produced an overall 12-month infertility prevalence of 7.9% (95% CI 6.6-12.7) in Burkina Faso, 29.6% (95% CI 15.3-100.0) in Côte d'Ivoire, 24.5% (95% CI 16.5-34.6) in Kenya, and 14.7% (95% CI 8.1-22.4) in Uganda. Results among women exposed to unprotected intercourse indicated much higher levels of infertility, ranging from 22.4% (95% CI 18.6-30.8) in Uganda to 63.7% (95% CI 48.8-87.9) in Côte d'Ivoire. Sensitivity analyses suggest infertility estimates are particularly sensitive to adjustments around pregnancy recognition timing and sexual activity, with little impact of adjustments for recent injectable contraceptive use, infertility treatment, and underreporting of traditional and coital dependent contraceptive use.
LIMITATIONS, REASONS FOR CAUTION: There was substantial digit preference in responses at 12 months, particularly among the tryers, which could introduce bias. Data quality concerns in the reproductive calendar may impact the accuracy of the CD approach among the broader sample of women exposed to unprotected sex, particularly with regard to underreported contraceptive use, induced and spontaneous abortions, and unrecognized pregnancies. Lastly, we lacked information on postpartum amenorrhea or abstinence.
Understanding the inconsistencies in definition and analytic approach and their implications for infertility estimation is important for reliably monitoring population-level infertility trends, identifying factors influencing infertility, improving prevention programs, and ensuring access to quality treatment and services.
STUDY FUNDING/COMPETING INTEREST(S): This study was supported by grants from the Bill & Melinda Gates Foundation (INV009639) and the National Institute of Child Health and Human Development (K01HD107172). The funders were not involved in the study design, analyses, manuscript writing, or the decision to publish. The authors have no conflicts of interest to declare.
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布基纳法索、科特迪瓦、肯尼亚和乌干达尝试怀孕的女性与有过无保护性行为的更广泛女性群体中，12个月不孕症的患病率是否存在差异，患病率估计值如何受到模型假设和调整的影响？
尝试怀孕女性中12个月不孕症的估计患病率在布基纳法索为8%，在科特迪瓦为30%，在有过无保护性行为的更多女性群体中大幅上升。
虽然生育是一种基本的人类经历，但女性和夫妇经历不孕症的程度是一个被忽视的研究领域，特别是在撒哈拉以南非洲。该地区现有的不孕症估计值差异很大，从2%到32%不等，然而，研究人群和模型假设的变异性的潜在影响尚未得到充分研究。
研究设计、规模、持续时间：我们使用了来自布基纳法索、科特迪瓦、肯尼亚和乌干达具有全国代表性的横断面调查数据。我们采用了多阶段整群随机抽样设计，每个国家内群的选择概率与群的大小成比例，以产生15-49岁女性的代表性样本。样本数量从科特迪瓦的3864个到肯尼亚的9489个不等。
参与者/材料、环境、方法：我们在每个国家创建了两个分析样本——尝试怀孕者样本和有过无保护性行为的更广泛女性样本——探索人群特征差异，并使用当前持续时间（CD）方法估计12个月不孕症的期间患病率。我们还研究了两个分析样本中每个样本内几个模型假设的影响，包括对近期注射用避孕药使用、未识别怀孕、不孕症治疗、避孕药使用报告不足以及性活动的调整。
在尝试怀孕者中采用CD方法得出，布基纳法索12个月不孕症的总体患病率为7.9%（95%置信区间6.6-12.7），科特迪瓦为29.6%（95%置信区间15.3-100.0），肯尼亚为24.5%（95%置信区间16.5-34.6），乌干达为14.7%（95%置信区间8.1-22.4）。有过无保护性行为女性的结果表明不孕症水平要高得多，从乌干达的22.4%（95%置信区间18.6-30.8）到科特迪瓦的63.7%（95%置信区间48.8-87.9）。敏感性分析表明，不孕症估计值对围绕怀孕识别时间和性活动的调整特别敏感，而对近期注射用避孕药使用、不孕症治疗以及传统和性交依赖避孕药使用报告不足的调整影响很小。
局限性、谨慎理由：在12个月时的回答中存在大量数字偏好，特别是在尝试怀孕者中，这可能会引入偏差。生殖日历中的数据质量问题可能会影响在有过无保护性行为的更广泛女性样本中CD方法的准确性，特别是在避孕药使用报告不足、人工流产和自然流产以及未识别怀孕方面。最后，我们缺乏关于产后闭经或禁欲的信息。
了解定义和分析方法的不一致性及其对不孕症估计的影响，对于可靠监测人群水平的不孕症趋势、识别影响不孕症的因素、改进预防计划以及确保获得优质治疗和服务非常重要。
研究资金/利益冲突：本研究得到了比尔及梅琳达·盖茨基金会（INV009,639）和国家儿童健康与人类发展研究所（K01HD107,172）的资助。资助者未参与研究设计、分析、稿件撰写或发表决定。作者声明无利益冲突。
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