The Paradigm of Infertility

Sovich-Sankoh Karmorh, MD

-An evolving era for Sub-Saharan Africa

By Dr. Sovich Sankoh-Karmorh

The traditional concepts versus the tested and proven realities as well as the way forward:

What makes lack of childbearing between couples in Sub-Saharan Africa a matter of urgency and immediate attention?

This article is constructively designed to partially outline some of the main reasons of the challenge which is usually associated, in most parts of Africa, with lack of proper medical diagnosis and investigation with subsequent treatment and or attempted treatment or remedies.

A lot of the myths we know about failure of childbearing in our setting is blamed on the female. If a woman fails to conceive after marriage, the cause of of the failure is immediately attributed to the her, thereby disregarding any reproductive issues her husband or partner may have.

This notion has been dispelled by neo-science and research, evidenced by the World Health Organization (WHO 2012) report on the infertile couple.

In this report, it is estimated that 48.5 million couples are affected globally and males are found to be solely responsible for 20-30% of the problem and contribute an overall 50% to the case overall. Female factors contribute 50% to all cases and the remaining 20-30% are due to a combination of factors from both couple.

Other researches include a 15% to the ratio, representing all unexplained cases. This means, both partners have been properly investigated and no physical or medical issues have been found to link to either of them to an infertility problem.

Infertility or sub fertility is failure of a non-contracepting couple to achieve a successful pregnancy after a year of unprotected coitus (sexual intercourse). Notice that the definition states “couple” meaning it takes two biologically opposite sexed individuals to conceive.

However, it is a choice for the both individuals in a union, more so in their right frames of mind to determine if they want pregnancy, when they want it and if so, to decide on the size of the family they would love to have.

It is somehow difficult to address the burden of infertility and its prevalence globally and this is because of lack of common tools to diagnose and report infertile couples, coupled with a lack of consistent use of definitions, which are critical barriers to reporting, (WHO/Petra Nohavicova reports).

Infertility has its own burden on the infertile couple. It can lead to shame, stigma and anxiety and even depression with low self-esteem and guilt.

Although many new options are available to resolve this problem, most couples in Sub-Saharan Africa still may not be able to access these services due to lack of its availability within countries and or cost of treatment, leaving them vulnerable to abuse and exploitation. (Mahmoud Fathalla, HRP 2010)

Most cases of subfertility in women are caused by anovulatory cycles or ovulation disorders. In such cases, the woman is receiving her monthly flow but mostly irregularly with long intervals between the last menstrual period (LMP) and the current one; or not receiving her period at all.

Normally a woman sees her period every 21-40 days; with an average of 28 day cycle for most. Anovulatory cycles do not release mature ovum (eggs, the female vehicle of reproduction), even if they are produced they are generally primary follicles with poor quality and not equipped for fertilization.

Another common condition associated with reproductive age women is polycystic ovarian syndrome, which is most often misdiagnosed, because of its associated endocrine disorder (obesity, hyperandrogenesim and hirsuitism). Additionally Premature ovarian failure is also one of the contributing factors to anovulatory cycles.

In addition to endocrine disorders, tubal problems appear to form a significant portion of the female infertility burden in Sub-Saharan Africa, typically because sexually transmitted diseases (STDs) and sexually transmitted infections (STIs) such as PIDS and syphilis are still major issues within child-bearing age women.

Moreover, uterine fibroids have become an annoying concern for most women as well. Although this condition may or may not contribute to the infertility, the fact that a woman has uterine fibroids whilst trying to conceive is a need for concern.

It has been noted from several clinical studies from the continent, that infertility makes up 25-50% of cases that visit the gynecologists. Of this amount more than half are diagnosed of secondary infertility.

This diagnosis, although evidenced based, requires require more research. This diagnosis is reached after delving into the patients’ reproductive history and investigating clinically.

Also, justifying this diagnosis is the fact that either of the partners has had a previous clinical successful pregnancy either with the current partner or a previous one.

Moreover, women who have had long periods of combined oral contraceptives or other methods tend to experience periods of subfertility once they stop the usage.

This is because of the ability of the method to affect the individual’s pre-existing fecundity potential.

We are not being controversial about contraception, nonetheless, we are recognizing that factors such as its long term usage, mode of action of the method used and adverse effects most probably lead to its long-term sequelae with reproduction.

Let’s state with emphasis that Family Planning worldwide has notably reduced the rate of unsafe abortions and encouraged planned parenthood. Most couples will conceive after a while without treatment but if the woman’s age is above 35, chances become slimmer.

On the other hand, male fertility problems range from abnormal sperm production or function to problems associated with delivery of the sperm. The former may originate from hereditary diseases or structural problems.

Additionally, environmental factors such as radiation, pesticides and other industrial chemicals have shown to harm sperm production and function; however, smoking and alcohol usage which were long being thought to affect male sperm semen production have not been clinically proven.

Nonetheless, over exposure may play a role in affecting fertility and it is advisable to either minimize smoking or cease for a period when you are trying to conceive.

Other chronic acquired diseases such as diabetes mellitus, cancers and inherited genetic conditions and their management may affect potency and sperm production.

What should now be a proper approach to Infertility?

Treatment for subfertility and infertility requires a thorough investigation of both the woman and her male partner.

A fertility specialist must assess all these parameters in both partners before submitting an informed decision. A clinician must first be aware of the cultural setting of a given infertile population.

The World Health Organization (WHO) defines traditional medicine as the sum total of the knowledge, skills, and practices based on the beliefs and experiences of different cultures, and it is used in physical and mental illness prevention, diagnosis, healing or treatment, as well as in maintaining good health.

For years now people have resorted to traditional practices to solve fertility problems.

Today, many traditional practices to solve fertility still vary from culture to culture worldwide, but with Sub-Sharan Africa, obvious similarities exist.

For example, most cultures in Africa still use methods such as visiting religious leaders, visiting tombs, killing a red rooster and feeding it to a child, using amulets, drinking Zamzam water (water brought from a holy pilgrimage), herbs, mineral supplements and vitamins, chiropractic, homeopathy and acupuncture to name to solve infertility problems.

In Nigeria and several other countries, in the sub-region, including Liberia visiting religious leaders, using amulets and folk medicine are some of the most common practices.

Issues to consider for remedy

A fertility clinician must assess all parameters for both partners before rendering a decision. In our African setting, men are the dominant figures and most do not attend clinics with their female partners.

In fact it becomes almost difficult to have male partners visit the fertility specialist for consultation, especially if he has had children from previous relationships. During such scenarios, appropriate counseling cannot be overly emphasized.

Experts should also be aware of traditional practices, respect their usage for individual couples and offer an appropriate medical option with patients’ consent, with the aim of improving fertility.

Also, there is a need to study widely used practices and evaluate the effects and benefits if any and for literate couples directing them to reliable sources  such as the internet aids in the process.

In conclusion, Infertility is a medical disease that affects anyone. The physical and mental dilemma attached overwhelming for most couples. It is, however, encouraging to note that every man can father a child and every woman too, regardless of the fertility issue, can father a child.

Couples need to seek help from the right sources if and when they have tried for more than a year and no clinically evident conception occurs.

Hopefully, Liberia is now heading in the direction of fertility treatment, a decision which is laudable and worth investing into. Needy couples can now access standard treatment at several private facilities within Monrovia and get a significant level of successful treatment without the burden of traveling to the sub region or beyond, a venture too costly for the average infertile couple.


  1. Mr. Editor,

    What’s about a little background on who the author of this medical article is? The source of the research upon which the article is based has a broad spectrum – Sub-Saharan Africa. No comparisons were made based on the regions of Sub-Saharan Africa – West Africa, Central Africa, Southern Africa, and East Africa.

    While the pathological and socioeconomic factors underlying the problem of infertility in Sub-Saharan African countries could be similar in several ways, there could be different nuances in the demography of the different regions stated supra. The breaking down of the greater region into its smaller regions for purposes of comparative analysis, could more likely paint a better picture of the causative factors that lead to infertility.


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