Infertility in Men and Women
1. Aidarbek Kyzy Aidanek
2. Sanket Bhale
Shivraj Dubal Vikramsinh Gawade
(1. Professor, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic.
2. Students, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic.)
Abstract
Infertility, defined clinically as the failure to achieve pregnancy after twelve months or more of regular unprotected sexual intercourse, represents a profoundly distressing condition that affects an estimated forty-eight million couples globally, translating to approximately one in seven couples of reproductive age. In a world where parenthood is not merely a personal milestone but a social imperative deeply woven into the fabric of familial identity and cultural continuity across diverse societies, the inability to conceive carries psychological burdens that frequently exceed the physical manifestations of underlying pathology. This review examines the dual burden of male and female infertility, exploring how the biological complexities of impaired spermatogenesis, ovulatory dysfunction, tubal disease, and endometrial receptivity intersect with patriarchal expectations that often render women solely responsible for reproductive failure despite male factors contributing to nearly half of all cases. Drawing upon the World Health Organization reproductive health databases, the International Committee for Monitoring Assisted Reproductive Technology registries, and multicenter studies from fertility clinics across developed and developing nations, we synthesize current understanding of the evolving epidemiology—including the alarming rise of male factor infertility attributed to environmental exposures and lifestyle transitions, and the polycystic ovary syndrome epidemic affecting women worldwide—the diagnostic algorithms adapted to resource-variable settings, and the assisted reproductive technologies that have transformed possibilities while creating new ethical and economic dilemmas. The findings reveal that while high-income countries have witnessed dramatic expansions in assisted conception availability, access to quality care remains stratified by geography and economy, with couples in low-resource settings facing diagnostic delays, untreated genital infections, and exploitation by unregulated practitioners. We discuss the specific vulnerabilities of diverse contexts, including the persistence of consanguineous unions in certain regions, the scourge of pelvic inflammatory disease and tuberculosis damaging fallopian tubes, the declining trends in semen quality observed across diverse populations, and the recent regulatory frameworks attempting to standardize assisted reproduction. This review argues that addressing infertility demands not merely technological proliferation of in vitro fertilization centers but a fundamental restructuring of reproductive health services to include male involvement, stigma reduction, prevention of preventable causes, and equitable access to evidence-based care that respects the dignity of couples navigating this deeply personal crisis.
Introduction
The consultation room of a fertility clinic in a metropolitan medical center witnesses a familiar choreography of anxiety and hope: the young couple seated side by side, the woman's face partially concealed, the man staring at the floor, both having traveled hours from their hometown where well-meaning relatives have already prescribed countless herbal remedies and spiritual interventions. They have been married three years, and in their community, the whispered speculation about "the bride's fault" has grown loud enough to threaten the woman's safety within her marital home, despite the fact that preliminary testing has already revealed severe oligospermia in the husband—a diagnosis he is reluctant to accept and she is forbidden to disclose. This scene, replicated daily across thousands of fertility clinics worldwide, illustrates the paradox of infertility in contemporary society: a medical condition equally distributed between sexes in its biological origins yet unequally burdened in its social consequences, surrounded by silence, shame, and a booming industry of promise that often outpaces scientific evidence.
The demographic significance of infertility extends beyond individual suffering to encompass population-level implications for nations navigating the demographic transition. While policy attention has focused historically on population control and contraception, the reality that millions of couples actively seek conception without success has only recently gained recognition as a legitimate public health concern. The prevalence estimates vary widely—from eight percent in some community-based surveys to over twenty percent in clinic-based studies—reflecting methodological variations, definitional differences, and the cultural reluctance to report childlessness that likely underestimates true burden. With over two billion married women of reproductive age globally, even conservative prevalence estimates suggest that one hundred forty to two hundred million couples experience infertility, constituting a population larger than many nations.
The epidemiological landscape of infertility is undergoing rapid transformation, shaped by urbanization, delayed marriage and childbearing, environmental degradation, and the obesity-diabetes epidemic. The age at first marriage for educated women has risen steadily across high-income and middle-income countries, with many postponing conceptions until their thirties when ovarian reserve declines precipitously. Simultaneously, semen quality appears to be deteriorating across diverse populations, with multiple studies documenting declining sperm counts, motility, and morphology over recent decades, attributed to endocrine-disrupting chemicals, heat exposure in occupational settings, pesticide residues, and the metabolic consequences of sedentary lifestyles. The polycystic ovary syndrome, affecting up to twenty percent of women in some populations, has emerged as the leading cause of anovulatory infertility, while genital infections—including tuberculosis in high-burden regions—continue to destroy fallopian tubes in thousands of young women annually.
The cultural context of infertility cannot be separated from its medical management. In societies structured around kinship and lineage, where religious traditions emphasize the duty of procreation and where elder care traditionally depends upon filial offspring, childlessness represents not merely a medical condition but a social catastrophe. Women bear the disproportionate weight of this stigma, frequently facing marital violence, abandonment, polygamy, or social ostracism regardless of whether the underlying pathology resides in them or their partners. The male factor, despite contributing to nearly fifty percent of infertile unions, often remains unacknowledged due to the equation of virility with masculinity, resulting in women undergoing unnecessary and invasive treatments while male partners resist semen analysis. This gendered dimension shapes health-seeking behavior, with couples delaying presentation until years of failed attempts have passed, often after exhausting traditional and alternative medicine options that deplete financial resources and narrow the window for effective intervention.
The regulatory environment governing infertility treatment has evolved significantly across jurisdictions, with many nations establishing national boards to oversee clinics, standardize practices, and prevent commercial exploitation. These legislative frameworks respond to concerns about the "Wild West" nature of the fertility industry, where success rates were often misrepresented, donor anonymity poorly protected, and surrogacy arrangements fraught with ethical violations. While such acts promise improved quality control and patient protection, implementation challenges remain formidable given the sheer scale of demand and the concentration of specialized services in metropolitan centers far from rural populations.
This review examines infertility in men and women as a complex biosocial phenomenon requiring integrated understanding of reproductive endocrinology, andrology, infectious disease, and social determinants. We explore the distinct etiological profiles affecting each sex, the diagnostic approaches appropriate for resource-limited settings, the spectrum of treatments from lifestyle modification through surgical correction to assisted conception, and the economic and ethical frameworks that govern access to care. Throughout, we maintain attention to the lived experience of affected couples—the grief of miscarriage after expensive treatment, the strain of marital relations under diagnostic scrutiny, the isolation from community celebrations of childbirth, and the hope that persists through multiple cycles of intervention. Our objective is to provide a comprehensive resource that informs clinical practice, guides policy development, and advocates for the destigmatization of infertility as a medical condition requiring compassionate, evidence-based care.
Methods
This narrative review was conducted through systematic examination of peer-reviewed literature, international registry data, and World Health Organization reports pertaining to infertility globally, with attention to both male and female factors and their intersection. Our search strategy encompassed PubMed, Embase, the Cochrane Library, and regional databases including the Journal of Obstetrics and Gynaecology, Indian Journal of Urology, Human Reproduction, and Fertility and Sterility using combinations of MeSH terms and keywords including "infertility," "subfertility," "male infertility," "female infertility," "azoospermia," "oligospermia," "polycystic ovary syndrome," "PCOS," "tubal infertility," "endometriosis," "varicocele," "assisted reproductive technology," "ART," "IVF," "ICSI," "intracytoplasmic sperm injection," "semen quality," "sperm count," "ovarian reserve," "anti-Mullerian hormone," "tuberculosis," "pelvic inflammatory disease," "reproductive health," "World Health Organization," "ICMART," and "stigma."
Key data sources include the World Health Organization Global Observatory on Infertility reports, the International Committee for Monitoring Assisted Reproductive Technology (ICMART) World Reports, the European Society of Human Reproduction and Embryology registries, the Society for Assisted Reproductive Technology United States data, and multicenter studies on semen quality trends from fertility clinics across diverse geographical regions. Studies on male factor infertility drew upon andrology literature documenting declining sperm parameters, while female factor literature emphasized PCOS epidemiology and tubal disease patterns.
The synthesis integrates endocrine and andrological evidence with social science research on stigma, health-seeking behavior, and gender dynamics. We have attempted to balance presentation of high-technology interventions available in metropolitan centers with attention to primary and secondary prevention strategies relevant to resource-limited settings, and to the cultural adaptations necessary for effective infertility care in diverse communities. Where evidence is limited, particularly regarding long-term outcomes of assisted reproduction and the epidemiology of male factor trends, we have indicated the need for further research while drawing upon global evidence adapted to contextual considerations.
Results
The Epidemiological Burden and Changing Trends
The prevalence of infertility reflects a complex interplay of biological, demographic, and social factors that defy simple characterization. Population-based estimates from demographic and health surveys indicate that approximately ten percent of currently married women aged fifteen to forty-nine have experienced childlessness or secondary infertility, though this figure likely underestimates true prevalence due to the exclusion of never-married women, the underreporting of male factor issues, and the definitional limitations that do not capture couples who have ceased trying after prolonged failure. Clinic-based studies suggest higher prevalence, with an estimated forty-eight million couples actively seeking fertility treatment globally, a figure that has grown steadily over the past two decades, driven by increasing awareness, reduced stigma in urban areas, and the expansion of specialized services.
The demographic transition has created a paradoxical situation where overall fertility rates decline while demand for fertility services escalates. The total fertility rate has fallen below replacement level in many high-income and middle-income countries, yet the absolute number of infertile couples continues to rise due to population momentum and the aging of the reproductive cohort as women delay marriage and first conception for education and career establishment. The mean age of women presenting to fertility clinics has increased from twenty-eight to thirty-three years over the past decade in many regions, with profound implications for success rates given the exponential decline in ovarian reserve after age thirty-five. Simultaneously, the prevalence of male factor infertility appears to be rising, with multiple cross-sectional studies documenting deteriorating semen quality over time. A landmark meta-analysis analyzing semen parameters from over forty thousand men across diverse geographical regions demonstrated a significant decline in sperm concentration, total motility, and normal morphology, with average sperm counts falling by nearly fifty percent over the study period, a trend consistent across continents and particularly concerning given the environmental and lifestyle factors driving deterioration.
The regional variation in infertility patterns reflects the diversity of genetic, environmental, and infectious disease exposures across global regions. Communities with higher rates of consanguineous marriage show increased autosomal recessive conditions including congenital absence of the vas deferens and primary ciliary dyskinesia. Regions with high burdens of genital tuberculosis, including South Asia and sub-Saharan Africa, demonstrate substantial proportions of female infertility attributable to tubal damage from previous or subclinical infection. Urban metropolitan areas show the highest rates of PCOS-related infertility, affecting up to twenty-five percent of women seeking treatment, while rural areas continue to face high rates of preventable infertility from untreated sexually transmitted infections and septic abortion complications.
Male Infertility: The Hidden Half
The evaluation of male infertility reveals a landscape dominated by oligospermia, asthenospermia, and teratospermia, with obstructive azoospermia and non-obstructive azoospermia representing less common but clinically significant categories. The recognition that male factors contribute to nearly forty to fifty percent of infertile unions has grown slowly in medical practice, where andrology remains a subspecialty with limited trained practitioners compared to the vast infrastructure for female infertility evaluation. The stigma surrounding male infertility—deeply threatening to concepts of masculinity and virility in patriarchal society—results in profound underreporting and delayed presentation, with men often refusing testing until female partners have undergone exhaustive and invasive evaluations.
Varicocele, the abnormal dilatation of the pampiniform plexus veins, represents the most common correctable cause of male infertility, present in approximately fifteen to twenty percent of the general male population and thirty-five to forty percent of men presenting with infertility. The high prevalence reflects genetic predisposition, upright posture, and possibly hot, humid climates that may exacerbate thermoregulatory impairment of spermatogenesis. Despite the association with impaired semen parameters, the causal relationship between varicocele and infertility remains debated, with surgical varicocelectomy improving pregnancy rates in selected cases but not universally indicated. The technique of microsurgical varicocelectomy, offering the lowest recurrence and complication rates, is available only in specialized centers, while high ligation or laparoscopic approaches remain more common in general surgical practice.
Infectious causes of male infertility, while declining with improved sanitation and antibiotic availability, remain significant in many regions. Genital tuberculosis can involve the epididymis, vas deferens, and seminal vesicles, causing obstructive azoospermia or severe oligospermia with necrospermia. Mumps orchitis in adolescence, inadequately prevented by vaccination coverage gaps in many areas, causes testicular atrophy and irreversible infertility. Sexually transmitted infections including gonorrhea and chlamydia, despite being treatable, frequently ascend to cause epididymo-orchitis and ductal obstruction due to delayed presentation and incomplete treatment in informal healthcare settings.
The emerging evidence regarding environmental and lifestyle factors in male infertility has particular resonance globally, where rapid industrialization has introduced endocrine-disrupting chemicals, heavy metals, and pesticides into the environment with limited regulatory oversight. Studies of men occupationally exposed to pesticides in agricultural settings, heavy metals in industrial zones, and heat in foundries and driving professions consistently demonstrate impaired semen parameters. The obesity epidemic, with abdominal adiposity promoting estrogenization through aromatase activity, compounds these environmental insults. The diagnosis of male infertility relies upon semen analysis following two to seven days of abstinence, with standardized parameters according to WHO criteria, though the concentration of specialized andrology laboratories in urban centers limits access for rural populations. Hormonal evaluation including follicle-stimulating hormone, luteinizing hormone, testosterone, and prolactin helps distinguish hypogonadotropic hypogonadism from primary testicular failure, while genetic testing including karyotype and Y-chromosome microdeletion analysis is indicated for azoospermia and severe oligospermia, available only in referral centers.
Female Infertility: The Ovarian, Tubal, and Uterine Dimensions
Female infertility presents a pattern varying by region, characterized by high rates of tubal factor infertility in infectious disease-burdened areas, the polycystic ovary syndrome epidemic in urbanizing populations, and the relatively lower but significant contribution of endometriosis and uterine factors. The evaluation of the female partner traditionally follows a systematic approach assessing ovarian reserve, tubal patency, and uterine cavity, though economic constraints often lead to empirical treatment before complete evaluation.
Ovarian dysfunction represents the leading cause of female infertility in contemporary practice, with polycystic ovary syndrome affecting twenty to twenty-five percent of reproductive-aged women in urban areas and increasingly recognized in rural populations. The phenotype in diverse women often emphasizes metabolic features including insulin resistance and central obesity rather than the hyperandrogenic symptoms of hirsutism and acne that predominate in Caucasian populations, potentially reflecting genetic background or diagnostic ascertainment through metabolic rather than dermatological presentation. The anovulation of PCOS responds to weight reduction, insulin sensitizers including metformin, and ovulation induction with clomiphene citrate or letrozole, though the multiple pregnancy risk with these agents requires careful monitoring. The age-related decline in ovarian reserve, accelerated by the trend toward delayed childbearing, is assessed by anti-Müllerian hormone levels and antral follicle count, with poor responders facing diminished success with assisted reproduction and the ethical and economic dilemmas of donor oocyte utilization.
Tubal factor infertility, while declining in developed nations with effective sexually transmitted infection control, remains devastatingly common in many regions, accounting for thirty to forty percent of female infertility in high-burden series. Genital tuberculosis, often presenting with subtle constitutional symptoms or asymptomatically, causes caseous necrosis and fibrosis of the fallopian tubes, endometrium, and ovaries, with diagnosis complicated by the paucibacillary nature of extrapulmonary disease and the limitations of endometrial histopathology, PCR, and culture. Pelvic inflammatory disease from bacterial sexually transmitted infections, septic abortion, or puerperal infection creates tubal damage through salpingitis, hydrosalpinx, and peritubal adhesions, with the chronic pelvic pain and dyspareunia accompanying these conditions further impairing sexual function and fertility.
Uterine factors including congenital anomalies such as septate uterus, acquired conditions including Asherman syndrome from post-abortion or post-partum curettage, and leiomyomas particularly submucosal fibroids, contribute to infertility through impaired implantation or early pregnancy loss. The diagnosis relies upon hysteroscopy and hysterosalpingography, with surgical correction of septa or synechiae and myomectomy for significant fibroids restoring fertility in selected cases. Endometriosis, while less prevalent in some populations, is increasingly recognized as a cause of infertility and pelvic pain, with diagnostic delays common due to normalization of dysmenorrhea and the stigma surrounding discussion of menstrual and sexual health.
Diagnostic and Therapeutic Approaches
The diagnostic evaluation of the infertile couple follows a phased approach adapted to economic and geographic constraints, beginning with history and physical examination of both partners, semen analysis, and basal investigations including thyroid function, prolactin, and ovarian reserve markers. The hysterosalpingogram, despite its discomfort and radiation exposure, remains the primary modality for tubal assessment in most settings due to lower cost compared to laparoscopic chromopertubation, though the latter offers the advantage of simultaneous therapeutic intervention for adhesions or endometriosis. Ultrasound monitoring of follicular development guides ovulation induction and timed intercourse or intrauterine insemination cycles.
Assisted reproductive technology has transformed the landscape of infertility treatment, with over eight million babies born worldwide from IVF and related techniques. The intracytoplasmic sperm injection technique, developed to overcome severe male factor infertility, is now utilized in over seventy percent of cycles due to its higher fertilization rates compared to conventional IVF, effectively bypassing mild to moderate sperm dysfunction. The cost of ART, while varying dramatically by jurisdiction, remains prohibitive for the majority of the global population, with a single IVF cycle costing between several thousand to tens of thousands of dollars, often requiring multiple attempts and creating catastrophic health expenditure that drives families into debt.
The surgical management of infertility includes laparoscopic adhesiolysis, tubal recanalization for sterilization reversal, myomectomy, and varicocelectomy, with microsurgical techniques for tubal anastomosis and vasovasostomy available in specialized centers. The role of hysteroscopic surgery for septal resection and polypectomy has expanded with improved instrumentation, offering outpatient solutions for uterine factors.
Discussion
The evidence synthesized in this review reveals infertility as a condition of vast scale and complex etiology, situated at the intersection of biological pathology and social suffering. The recognition that male and female factors contribute with near equal frequency demands a paradigm shift from the traditional focus on female evaluation and treatment toward couple-based care that destigmatizes male factor issues and encourages early assessment of both partners. Yet the persistence of patriarchal norms that equate fertility with feminine worth and virility with masculine identity continues to distort health-seeking behavior, with women undergoing years of unnecessary treatment while male partners resist testing, and with the emotional burden of failure falling disproportionately upon wives regardless of medical findings.
The rising prevalence of male factor infertility, documented through declining sperm quality across diverse populations, represents a public health crisis that demands investigation into environmental exposures, occupational hazards, and lifestyle factors including obesity, heat exposure, and endocrine-disrupting chemicals. The regulatory framework for industrial safety and environmental protection requires strengthening to address these reproductive toxicants, while workplace interventions for men in high-heat or chemical-exposed occupations could prevent iatrogenic infertility.
The tuberculosis-infertility nexus remains a particular tragedy for women in high-burden regions, with genital TB causing irreversible damage that could be prevented through early detection and treatment of pulmonary disease, and through improved surgical safety to prevent post-abortion sepsis. The integration of infertility prevention into reproductive health programs—through STI control, safe abortion services, and TB screening—offers cost-effective strategies that receive inadequate attention compared to the high-profile proliferation of IVF centers.
The assisted reproduction industry, while offering genuine hope to millions, requires continued regulatory oversight to prevent exploitation, ensure truthful advertising of success rates, protect donor and surrogate rights, and maintain quality standards. Legislative frameworks provide the structure, but implementation requires sustained investment in inspection, accreditation, and patient education to navigate the complex landscape of treatment options.
Conclusion
Infertility in men and women represents a medical condition of profound personal and social significance, affecting millions of couples who navigate the pain of unfulfilled parenthood within cultural contexts that rarely offer compassion for their struggle. The biological realities of declining semen quality, the PCOS epidemic, tubal damage from infection, and age-related ovarian senescence create a perfect storm of reproductive difficulty that confronts couples already stressed by economic uncertainty and social expectation.
The path forward demands the normalization of male infertility evaluation to eliminate gender-blame, the prevention of infectious causes of tubal damage through improved public health, the regulation of environmental toxicants threatening semen quality, and the expansion of insurance coverage or public financing for fertility treatment to reduce the catastrophic costs that currently restrict access to the affluent. For couples worldwide, the ability to conceive should not depend upon their wealth, their geography, or their willingness to endure years of blame and isolation, but upon the universal availability of compassionate, evidence-based reproductive healthcare that recognizes the equal dignity of both partners in the journey toward parenthood.
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