Please provide me basic fact sheets on infertility worldwide and in nepal with references along with frequently asked questions and their answers
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PMID: 40656916
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I have sufficient data from the textbooks and Nepal-specific PubMed studies to now compile a thorough, well-referenced fact sheet. Let me write the comprehensive response.
Infertility Fact Sheets: Worldwide and Nepal
PART 1: GLOBAL FACT SHEET ON INFERTILITY
Definition
Infertility is defined by the World Health Organization (WHO) as "a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse." In women aged 35 and older, the evaluation threshold is reduced to 6 months. Sterility refers to a total inability to reproduce.
- Harrison's Principles of Internal Medicine, 22nd Edition (2025), p. 3193
- Goldman-Cecil Medicine International Edition, p. 2561
Global Burden and Prevalence
| Indicator | Data |
|---|---|
| Global prevalence | ~17.5% of the adult population |
| Couples affected | 48-72 million couples worldwide |
| Ranking among diseases | 3rd most common disease worldwide |
| Couples conceiving within 12 months | ~85% |
| Couples conceiving within 24 months | ~95% |
| Prevalence in developed countries | 3.5-16.7% |
| Prevalence in developing nations | 6.9-9.3% |
"Infertility is the third most common disease worldwide, affecting ~48-72 million couples. The prevalence of infertility, ~17.5% globally, has remained relatively stable over the past few decades."
- Harrison's Principles of Internal Medicine, 22nd Ed., p. 3193
The fecundability rate (probability of achieving pregnancy in one menstrual cycle) is highest in the first 3 months of attempting conception and declines over the following 9 months. A trend toward later childbearing globally has significant implications because fecundability declines sharply with maternal age:
| Maternal Age | Reduction in Fecundability vs. Age 30-31 |
|---|---|
| 34-35 years | -14% |
| 36-37 years | -19% |
| 40-41 years | -53% |
| 42-44 years | -59% |
Harrison's Principles of Internal Medicine, 22nd Ed., p. 3193
Types of Infertility
Primary infertility: Couples who have never achieved a pregnancy.
Secondary infertility: Infertility occurring after at least one prior successful pregnancy.
Causes and Contributing Factors
The causes are broadly categorized as female factors, male factors, combined, and unexplained.
Distribution (Harrison's 2025)
| Factor | Percentage of Couples |
|---|---|
| Female factor alone | 30-40% |
| Male factor alone | 40-50% |
| Both male and female | 20-30% |
| Unexplained | Up to 30% |
Male Causes (~40%)
- Decreased sperm production: Varicocele (most common), testicular failure, cryptorchidism, endocrine disorders
- Ductal obstruction: Post-infection epididymis, congenital absence of vas deferens, post-vasectomy
- Ejaculatory dysfunction: Hypospadias, retrograde ejaculation, psychogenic causes
- Abnormal semen: Infection, abnormal volume or viscosity
- Genetic factors: Klinefelter syndrome, Y chromosome microdeletions, defects in spermatogenesis
- Lifestyle factors: Stress, smoking, caffeine, nicotine, recreational drugs
Female Causes (~60%)
- Tubal disease (20-30%): Pelvic inflammatory disease (PID), prior pelvic surgery, salpingitis, endometriosis, adhesions
- Ovulatory dysfunction (15%): Polycystic ovary syndrome (PCOS), diminished ovarian reserve, premature ovarian insufficiency
- Uterine and cervical factors (10%): Fibroids, polyps, congenital malformations, intrauterine adhesions (Asherman syndrome)
- Endocrine causes: Hypothyroidism, hyperprolactinemia
- Vaginal factors (<5%): Vaginismus, vaginitis, congenital abnormalities
- Immunologic factors (<5%): Sperm-immobilizing or sperm-agglutinating antibodies
- Nutritional and metabolic factors (5%): Thyroid disorders, diabetes, severe nutritional deficiency
- Unexplained (<10%)
Goldman-Cecil Medicine, p. 2561-2562; Harrison's 2025, p. 3193
"In approximately 40% of cases, infertility is caused by the male. In one third of couples, more than one cause contributes to the infertility." - Goldman-Cecil Medicine, p. 2561
Diagnostic Evaluation
- Both partners must be evaluated, with separate and joint interviews.
- Male evaluation: Semen analysis (volume, count, motility, morphology)
- Female evaluation:
- Documentation of ovulation: basal body temperature, serum progesterone (day 21), FSH/LH, thyroid function
- Anti-Mullerian hormone (AMH) for ovarian reserve
- Hysterosalpingography (HSG) or sonohysterography for tubal/uterine assessment
- Diagnostic laparoscopy for suspected tubal or pelvic disease (gold standard)
- Evaluation should start at 12 months in women <35, at 6 months in women 35-39, and immediately in women ≥40.
Goldman-Cecil Medicine, p. 2561; Harrison's 2025, p. 3193
Treatment Options
| Condition | Treatment |
|---|---|
| Anovulation (without hyperprolactinemia) | Clomiphene citrate 50 mg/day x 5 days (1st line); dose escalated 50 mg/cycle if no ovulation |
| Anovulation (with hyperprolactinemia) | Bromocriptine or cabergoline |
| Hypogonadotropic hypogonadism | Exogenous gonadotropins (FSH + hCG) |
| Tubal obstruction | Surgical repair or IVF |
| Endometriosis | Surgery, suppressive drugs, IVF |
| Male factor (low sperm count/motility) | Donor insemination or IVF with ICSI |
| Unexplained infertility | Ovarian stimulation + IUI, or IVF |
Assisted Reproductive Technologies (ART):
- IVF (In Vitro Fertilization): Egg retrieval after ovarian stimulation, fertilization in laboratory, embryo transfer
- ICSI (Intracytoplasmic Sperm Injection): Single sperm injected directly into egg - preferred for severe male factor
- IUI (Intrauterine Insemination): Sperm placed directly into uterus around ovulation time
- Donor gametes: Donor sperm or eggs when partner's gametes are unusable
Goldman-Cecil Medicine, p. 2562
Social and Psychological Impact
- Infertility causes significant psychological distress, including anxiety, depression, social isolation, and marital strain.
- Globally, stigma around infertility - particularly in South Asian and African cultures - disproportionately burdens women regardless of the cause.
- Sperm count has declined significantly over recent decades. A landmark 2023 meta-analysis (Levine et al., Human Reproduction Update) documented declining sperm counts globally from the late 20th to 21st century. [PMID: 36377604]
PART 2: INFERTILITY IN NEPAL - FACT SHEET
Overview
Nepal faces a significant infertility burden, compounded by limited healthcare infrastructure, strong cultural pressures for childbearing, social stigma, and restricted access to specialist reproductive care, especially in rural areas.
Prevalence and Clinical Profile
| Indicator | Nepal Data |
|---|---|
| Type most commonly seen | Primary infertility (~74.7-72.94% of cases) |
| Female-factor infertility | ~48.8% (Dhulikhel Hospital series) |
| Male-factor infertility | ~23.9% |
| Mixed (both partners) | ~26.6% |
| Unexplained infertility | ~14.4% |
| Mean age of women seeking treatment | 26.85 ± 4.78 years |
| Mean age of men seeking treatment | 29.81 ± 3.18 years |
Sources:
- Tamrakar SR, Bastakoti R. "Determinants of Infertility in Couples." J Nepal Health Res Counc. 2019. [PMID: 31110383] - Based on 3,231 infertile couples at Dhulikhel Hospital, 2008-2018.
- Sharma J et al. "Clinical Profile of Patients with Infertility Presenting to Tertiary Care Center." JNMA. 2025. [PMID: 40656916] - Study of 170 couples, Dec 2023 - May 2024.
Leading Causes in Nepal
In Women (Nepal Data)
| Cause | Frequency (Sharma et al. 2025) |
|---|---|
| Tubal blockage | 21.76% of women |
| Polycystic ovarian disease (PCOD) | 9.41% |
| Elevated AMH (linked to PCOS) | 40% |
| Fibroids | 3.53% |
| Ovulatory disorders (across series) | 52.12% of female factors (Tamrakar & Bastakoti) |
| Tubal disease (laparoscopy series) | 62% had tubal block on laparoscopy (Subedi et al. 2020) |
| Endometriosis | 50% on laparoscopy (Subedi et al. 2020) |
| Peritubal adhesions | 63% on laparoscopy (Subedi et al. 2020) |
In Men (Nepal Data)
| Cause | Frequency |
|---|---|
| Semen abnormalities | 34.12% of men |
| Oligospermia (most common) | 14.71% |
| Other sexual dysfunction | 1.2% |
Source: Sharma et al. 2025 [PMID: 40656916]; Subedi et al. 2020 [PMID: 34506402]; Tamrakar & Bastakoti 2019 [PMID: 31110383]
Diagnostic Findings (Laparoscopy, Eastern Nepal)
A cross-sectional study at Nobel Medical College, Eastern Nepal (Subedi et al., JNMA, 2020 [PMID: 34506402]) of 100 infertile women who underwent diagnostic laparoscopy found:
- 62% had tubal disease (unilateral or bilateral block)
- 63% had peritubal adhesions
- 15% had hydrosalpinx
- 50% had endometriosis (cysts, adhesions, partial/complete obliteration of Pouch of Douglas)
This underscores the high burden of preventable pelvic infections and STI-related tubal disease in Nepal.
Psychological Impact in Nepal
A 2026 cross-sectional study in Kathmandu (Dawadi et al., BMC Women's Health [PMID: 41709186]) of 182 women with infertility found:
- 38% had depressive symptoms (over 10% with moderate to severe depression)
- Factors significantly associated with depression included: ethnicity, husband's education/occupation, chronic disease, history of abortion, type of family structure, and emotional support from husband
- Treatment rigidity/schedule burden was also a significant contributor
- The authors highlighted infertility as a "neglected area in the health care delivery system" in Nepal
Socio-Cultural Context in Nepal
- Strong cultural and societal pressure for childbearing, especially on women
- Infertility is frequently blamed on the woman, regardless of etiology, leading to discrimination, abandonment, and domestic abuse
- Social stigma leads to delayed care-seeking and reliance on traditional healers
- Most infertility services are concentrated in Kathmandu and urban centers; rural populations have severely limited access
- Economic barriers restrict access to ART procedures (IVF/ICSI), which are expensive and not covered by national insurance
Available Services in Nepal
- Tertiary centers offering infertility workup and ART are primarily in Kathmandu Valley (e.g., Paropakar Maternity and Women's Hospital, Dhulikhel Hospital, teaching hospitals)
- Laparoscopy for both diagnosis and treatment is available at select centers
- IVF services are available in Kathmandu but at high out-of-pocket cost
- No national infertility registry or standardized data collection system exists
PART 3: FREQUENTLY ASKED QUESTIONS (FAQs)
Q1. What is infertility?
Infertility is the inability to achieve a clinical pregnancy after 12 or more months of regular, unprotected sexual intercourse. For women aged 35 or older, the evaluation is recommended after 6 months. It is classified as a disease of the reproductive system by the WHO.
Q2. How common is infertility worldwide?
Infertility affects approximately 17.5% of the global adult population, impacting an estimated 48-72 million couples. It is considered the third most common disease in the world. The prevalence has remained relatively stable over recent decades. (Harrison's 2025, p. 3193)
Q3. What is the difference between primary and secondary infertility?
- Primary infertility means the couple has never achieved a pregnancy.
- Secondary infertility means the couple has had at least one prior pregnancy but is now unable to conceive again.
In Nepal, approximately 72-75% of cases presenting to hospitals are primary infertility. (Tamrakar & Bastakoti 2019; Sharma et al. 2025)
Q4. Is infertility always a "female problem"?
No. Male factors account for 40-50% of all infertility cases. Female factors account for 30-40%. In 20-30% of couples, both partners have contributing abnormalities. A complete evaluation of both partners is always necessary. (Harrison's 2025, p. 3193)
Q5. What are the most common causes of infertility in women?
- Ovulatory disorders: PCOS, diminished ovarian reserve, premature ovarian insufficiency
- Tubal disease: From prior pelvic infections (PID), surgery, endometriosis
- Uterine factors: Fibroids, polyps, intrauterine adhesions
- Endocrine disorders: Hypothyroidism, hyperprolactinemia
- Cervical factors and immunologic causes
In Nepal, ovulatory disorders and tubal disease are the two most frequent female causes. (Tamrakar & Bastakoti 2019 [PMID: 31110383])
Q6. What are the most common causes of male infertility?
- Varicocele (enlarged veins in the scrotum, most treatable cause)
- Abnormal sperm parameters (oligospermia, asthenospermia, teratospermia)
- Ductal obstruction (post-infection, post-vasectomy)
- Genetic defects (Klinefelter syndrome, Y-chromosome microdeletions)
- Hormonal imbalances
- Lifestyle factors: Smoking, alcohol, obesity, heat exposure, recreational drugs
In Nepal, oligospermia is the most common specific finding in men with infertility. (Sharma et al. 2025 [PMID: 40656916])
Q7. At what age does fertility start declining?
Peak fertility in women is around age 25. The decline accelerates after 35, with a 53% reduction in fecundability by ages 40-41 compared to women aged 30-31. Male fertility also declines with age, though less steeply than female fertility, and is less pronounced before age 50. (Harrison's 2025, p. 3193)
Q8. How is infertility evaluated?
Evaluation includes:
- For both partners: Detailed history, physical examination
- Male: Semen analysis (at least 2 samples)
- Female: Ovulation assessment (progesterone, LH, FSH), thyroid and prolactin levels, AMH for ovarian reserve, pelvic ultrasound, hysterosalpingography (HSG), and laparoscopy if indicated
The evaluation should assess both partners simultaneously from the start.
Q9. What is unexplained infertility?
Unexplained infertility is diagnosed when no cause is identified after a complete fertility workup of both partners. It occurs in up to 30% of infertile couples globally. (Harrison's 2025) Management often involves ovarian stimulation with IUI or IVF.
Q10. What treatment options are available?
Treatment depends on the underlying cause:
- Ovulation induction: Clomiphene citrate (1st line), letrozole, gonadotropins (FSH injections)
- Surgery: For tubal disease, endometriosis, fibroids, varicocele repair
- ART (Assisted Reproductive Technologies):
- IUI (Intrauterine insemination) - less invasive, lower success rate
- IVF (In Vitro Fertilization) - eggs removed, fertilized in lab, embryo transferred
- ICSI (Intracytoplasmic Sperm Injection) - for severe male factor infertility
- Donor gametes: Donor sperm or donor eggs when applicable
- Treatment of underlying conditions: Thyroid disorders, hyperprolactinemia, PCOS management
Q11. Does infertility affect mental health?
Yes, significantly. A Kathmandu-based study found that 38% of women with infertility had depressive symptoms, with over 10% experiencing moderate to severe depression. Anxiety, social isolation, marital conflict, and reduced quality of life are well-documented. (Dawadi et al. 2026, BMC Women's Health [PMID: 41709186]) Psychological counseling should be integrated into infertility care.
Q12. Is infertility preventable?
Partially. Several causes are preventable:
- Prevention and early treatment of STIs/PID reduces tubal disease
- Avoiding smoking, alcohol, and drug use improves sperm and egg quality
- Maintaining healthy weight reduces PCOS risk and improves hormonal balance
- Avoiding unnecessary delay in childbearing preserves age-related fertility
- Treating conditions like thyroid disease and hyperprolactinemia
Q13. What is the situation with infertility services in Nepal?
Specialist infertility services are mostly available in Kathmandu. Most rural Nepalese have limited access to diagnosis and treatment. IVF is available but expensive, with no state subsidy. Cultural stigma - especially toward women - delays care-seeking. There is no national infertility registry. Research from tertiary hospitals indicates tubal disease, PCOS, and male semen abnormalities as the leading causes. (Tamrakar & Bastakoti 2019; Subedi et al. 2020; Sharma et al. 2025)
Q14. Are there lifestyle modifications that can improve fertility?
Yes:
- Achieving and maintaining a healthy BMI
- Quitting smoking and alcohol
- Reducing caffeine intake
- Managing stress (chronic stress is linked to ovulatory dysfunction)
- Treating underlying medical conditions (diabetes, thyroid)
- Having regular intercourse, especially around the time of ovulation (days 11-14 of a 28-day cycle)
Q15. When should a couple in Nepal seek help?
- Under 35: After 12 months of trying without success
- Aged 35-39: After 6 months
- Aged 40 or older: Immediately
- Any age if there is a known risk factor (prior PID, irregular periods, previous surgery, known male factor)
References
-
Harrison's Principles of Internal Medicine, 22nd Edition (2025). McGraw Hill Medical. Chapter 408: Infertility. pp. 3193-3197.
-
Goldman-Cecil Medicine International Edition. Elsevier. Chapter 218: Infertility. pp. 2561-2562.
-
Tamrakar SR, Bastakoti R. "Determinants of Infertility in Couples." Journal of Nepal Health Research Council. 2019 Apr; 17(1):99-103. doi:10.33314/jnhrc.1827. [PMID: 31110383] - Retrospective study of 3,231 couples, Dhulikhel Hospital 2008-2018.
-
Sharma J, Shrestha D, Thapa D, Rawal S, Kafle R. "Clinical Profile of Patients with Infertility Presenting to Tertiary Care Center: An Observational Study." JNMA Journal of the Nepal Medical Association. 2025 Mar. doi:10.31729/jnma.8925. [PMID: 40656916]
-
Subedi SS, Bhansakarya R, Shrestha P, Sharma SK. "Outcome of Laparoscopy in Infertile Couples attending a Teaching Hospital in Eastern Nepal." JNMA Journal of the Nepal Medical Association. 2020. doi:10.31729/jnma.5542. [PMID: 34506402]
-
Dawadi P, Shrestha S, Dawadee P, Gautam R. "Psychological impact of infertility on women in Kathmandu, Nepal: a cross-sectional study of depressive symptoms and associated factors." BMC Women's Health. 2026 Feb. doi:10.1186/s12905-026-04349-7. [PMID: 41709186]
-
Levine H et al. "Temporal trends in sperm count: a systematic review and meta-regression analysis of samples collected globally in the 20th and 21st centuries." Human Reproduction Update. 2023 Mar. [PMID: 36377604]
-
World Health Organization (WHO). Definition of infertility and reproductive health guidelines. Available at: who.int/reproductivehealth
Note: Prevalence figures for Nepal from hospital-based studies reflect patients presenting to tertiary care centers and may not represent population-level prevalence. A national community-based epidemiological study on infertility in Nepal remains a significant research gap.
Please provide me basic fact sheets on infertility worldwide and nepal latest
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WHO infertility fact sheet 2023 2024 global prevalence 17.5 percent
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WHO 2023 infertility global fact sheet 17.5 percent 1 in 6 people reproductive health
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PMID: 38224730
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https://www.who.int/news-room/fact-sheets/detail/infertility
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INFERTILITY FACT SHEETS
Global & Nepal - Latest Evidence (2025-2026)
FACT SHEET 1: INFERTILITY WORLDWIDE
1. Definition
The World Health Organization (WHO) defines infertility as "a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse."
- Primary infertility - the couple has never achieved a pregnancy
- Secondary infertility - infertility occurring after at least one prior successful pregnancy
- Sterility - total, permanent inability to reproduce
Harrison's Principles of Internal Medicine, 22nd Ed. (2025), p. 3193; Goldman-Cecil Medicine, p. 2561
2. Global Magnitude
| Indicator | Figure |
|---|---|
| Global prevalence | ~17.5% of the adult population |
| Estimated couples affected worldwide | 48-72 million couples |
| Rank among all diseases globally | 3rd most common disease |
| Prevalence in developed countries | 3.5-16.7% |
| Prevalence in developing nations | 6.9-9.3% |
| Couples conceiving within 12 months | ~85% |
| Couples conceiving within 24 months | ~95% |
"Infertility is the third most common disease worldwide, affecting ~48-72 million couples. The prevalence of infertility, ~17.5% globally, has remained relatively stable over the past few decades." - Harrison's Principles of Internal Medicine, 22nd Ed. (2025), p. 3193
In 2023, the WHO updated its global estimate, confirming approximately 1 in 6 people worldwide are affected by infertility at some point in their lifetime.
3. Age and Fertility - Key Facts
The fecundability rate (chance of conceiving in a single menstrual cycle) is highest in the first 3 months of trying and declines thereafter. Advanced age has a disproportionate impact on female fertility:
| Female Age | Reduction in Fecundability vs. Age 30-31 |
|---|---|
| 34-35 years | -14% |
| 36-37 years | -19% |
| 40-41 years | -53% |
| 42-44 years | -59% |
Peak female fertility is age 25. For nulliparous women aged 25, average time to conception is 5.3 months; for parous women, 2.7 months.
Harrison's 2025, p. 3193; Goldman-Cecil Medicine, p. 2561
4. Causes of Infertility
Overall Distribution (Harrison's 2025)
| Factor | Proportion of Infertile Couples |
|---|---|
| Male factor alone | 40-50% |
| Female factor alone | 30-40% |
| Both male and female | 20-30% |
| Unexplained infertility | Up to 30% |
"A complete workup of both partners is recommended in all couples presenting with infertility." - Harrison's 2025, p. 3193
Male Causes (~40-50%)
| Category | Examples |
|---|---|
| Decreased sperm production | Varicocele (most treatable), testicular failure, cryptorchidism, endocrine disorders |
| Ductal obstruction | Post-infection epididymal block, congenital absence of vas deferens, post-vasectomy |
| Ejaculatory dysfunction | Retrograde ejaculation, hypospadias |
| Endocrine causes | Hypogonadotropic hypogonadism, hypothyroidism, hyperprolactinemia, morbid obesity |
| Genetic causes | Klinefelter syndrome (47,XXY), Y-chromosome microdeletions |
| Sexual dysfunction | Erectile dysfunction, decreased libido |
| Lifestyle factors | Smoking, alcohol, anabolic steroids, excessive heat exposure, recreational drugs |
| Semen abnormalities | Abnormal volume, viscosity, or immunologic factors |
Female Causes (~30-40%)
| Category | Examples |
|---|---|
| Tubal factor (30-35% of female infertility) | PID, endometriosis, prior pelvic surgery, salpingitis isthmica nodosa, hydrosalpinx |
| Ovulatory dysfunction (15%) | PCOS, diminished ovarian reserve, premature ovarian insufficiency |
| Uterine/cervical (10%) | Fibroids, polyps, congenital anomalies, Asherman syndrome (intrauterine adhesions) |
| Endocrine causes | Hypothyroidism, hyperprolactinemia |
| Nutritional/metabolic (5%) | Thyroid disorders, diabetes, severe nutritional deficiency |
| Vaginal factors (<5%) | Vaginismus, vaginitis, congenital absence of vagina |
| Immunologic (<5%) | Sperm-immobilizing or sperm-agglutinating antibodies |
| Unexplained (<10%) | No cause found after complete workup |
Goldman-Cecil Medicine, p. 2561-2562; Harrison's 2025, p. 3193
5. Diagnostic Evaluation
When to start evaluation:
- Women <35 years: after 12 months of trying
- Women 35-39 years: after 6 months
- Women ≥40 years: immediately
- Any age if risk factors present (irregular periods, known pelvic disease, prior STI, male factor)
Both partners are evaluated simultaneously.
| Investigation | Purpose |
|---|---|
| Semen analysis (x2) | Sperm count, motility, morphology, volume |
| Serum FSH + Estradiol (Day 2-3) | Ovarian reserve |
| Anti-Mullerian Hormone (AMH) | Ovarian reserve, antral follicle count |
| Serum progesterone (Day 21) | Confirm ovulation |
| TSH, Prolactin, Androgens | Rule out endocrine causes |
| Pelvic ultrasound (transvaginal) | Uterus, ovaries, antral follicle count |
| Hysterosalpingogram (HSG) | Tubal patency, uterine cavity |
| Saline infusion sonogram | Intrauterine pathology |
| Diagnostic laparoscopy | Gold standard for tubal/pelvic disease (selective use) |
Harrison's 2025, p. 3193-3194
Note: Postcoital test, endometrial biopsy, thrombophilia, immunologic testing, and karyotyping are NOT indicated as part of routine initial workup (Harrison's 2025).
6. Treatment Options
Preconception Counseling (Always First)
- Weight management (obesity worsens anovulation, sperm parameters)
- Smoking cessation (reverses detrimental impact on fecundity; reduces ovarian reserve by accelerating menopause by 1-4 years)
- Limit caffeine to ≤2 cups/day
- Stop testosterone/androgen products
- Time intercourse every 1-2 days during fertile window (5-6 days before ovulation)
Medical and Surgical Treatments
| Indication | Treatment |
|---|---|
| Anovulation (PCOS) | Letrozole (1st line aromatase inhibitor); Clomiphene citrate (2nd line); Metformin as add-on |
| Hypothalamic amenorrhea | Weight gain, reduced exercise; low-dose gonadotropins if unresponsive |
| Hyperprolactinemia | Cabergoline or bromocriptine |
| Hypothyroidism | Levothyroxine |
| Diminished ovarian reserve | IUI + ovulation induction → escalate to IVF; donor oocytes |
| Tubal factor infertility | IVF (first choice); tubal repair (selected proximal blocks only) |
| Hydrosalpinx | Salpingectomy before IVF (removes toxic tubal fluid, improves IVF success) |
| Uterine fibroids/polyps | Hysteroscopic resection |
| Mild-moderate male factor | IUI ± ovulation induction |
| Severe male factor | IVF + ICSI |
| Azoospermia (obstructive) | Sperm retrieval (TESA/TESE) + ICSI |
Assisted Reproductive Technologies (ART)
| Technology | Description |
|---|---|
| IUI (Intrauterine Insemination) | Washed concentrated sperm deposited directly into uterine cavity via soft catheter |
| IVF (In Vitro Fertilization) | Eggs harvested after ovarian stimulation, fertilized in lab, embryo transferred to uterus at day 3 (cleavage) or day 5 (blastocyst) |
| ICSI (Intracytoplasmic Sperm Injection) | Single morphologically normal sperm injected into oocyte; used for severe male factor |
| Donor oocytes/sperm | Used when partner gametes are unsuitable; donor undergoes IVF procedure |
Harrison's 2025, p. 3194-3195; Goldman-Cecil Medicine, p. 2562
7. Psychological Impact
Anxiety, depression, and reduced quality of life are prevalent in both men and women experiencing infertility. A 2024 global review in Fertility and Sterility (Braverman et al. [PMID: 38224730]) of 366 articles over 10 years confirmed that:
- Depression, anxiety, and stress are consistent findings across infertility populations worldwide
- Experiences are similar across cultures
- Psychological support should be an integrated component of infertility care
8. Declining Sperm Counts - Emerging Concern
A 2023 landmark meta-analysis (Levine et al., Human Reproduction Update [PMID: 36377604]) documented a significant global decline in sperm counts during the 20th and 21st centuries, raising concern about environmental, dietary, and lifestyle determinants of male reproductive health. This trend has implications for future global fertility rates.
FACT SHEET 2: INFERTILITY IN NEPAL
1. Overview
Nepal faces a substantial infertility burden. The country's predominantly agrarian society places strong cultural importance on childbearing, particularly for women, making infertility a serious psychosocial issue. Access to specialist reproductive care is largely confined to urban centers, creating major disparities for rural populations.
2. Prevalence Data
Nepal lacks a national community-based infertility prevalence survey. Available data come from hospital-based series:
| Indicator | Data | Source |
|---|---|---|
| Global comparative prevalence (developing nations) | 6.9-9.3% | Sharma et al., 2025 |
| Primary infertility (hospital series) | 72.94-74.7% of all cases | Sharma et al. 2025; Tamrakar & Bastakoti 2019 |
| Secondary infertility | 25.3-27.06% | Sharma et al. 2025; Tamrakar & Bastakoti 2019 |
| Median duration of marriage at presentation | 5 years (IQR: 4-7) | Sharma et al. 2025 |
| Mean age of women presenting | 26.85 ± 4.78 years | Tamrakar & Bastakoti 2019 |
| Mean age of men presenting | 29.81 ± 3.18 years | Tamrakar & Bastakoti 2019 |
3. Causes of Infertility in Nepal
Causal Distribution (Tamrakar & Bastakoti, 2019 - 3,231 couples, Dhulikhel Hospital)
| Factor | Percentage |
|---|---|
| Female factor alone | 48.8% |
| Male factor alone | 23.9% |
| Combined (both partners) | 26.6% |
| Unexplained | 14.4% |
Specific Female Causes
| Cause | Data |
|---|---|
| Ovulatory disorders (overall) | 52.12% of female infertility (Tamrakar & Bastakoti 2019) |
| Tubal blockage | 21.76% of women (Sharma et al. 2025) |
| PCOS / polycystic ovarian disease | 9.41% of women (Sharma et al. 2025) |
| Elevated AMH (PCOS-linked) | 40% of women (Sharma et al. 2025) |
| Fibroids | 3.53% of women (Sharma et al. 2025) |
| Tubal disease on laparoscopy | 62% had tubal block (Subedi et al. 2020, n=100) |
| Peritubal adhesions | 63% on laparoscopy (Subedi et al. 2020) |
| Hydrosalpinx | 15% on laparoscopy (Subedi et al. 2020) |
| Endometriosis | 50% on laparoscopy (Subedi et al. 2020) |
Specific Male Causes
| Cause | Data |
|---|---|
| Semen abnormalities (total) | 34.12% of men (Sharma et al. 2025) |
| Oligospermia (most common) | 14.71% of men (Sharma et al. 2025) |
| Abnormal semen analysis | 22.7% of cases (Tamrakar & Bastakoti 2019) |
| Other sexual dysfunction | 1.2% (Tamrakar & Bastakoti 2019) |
"Infertility is rarely due to a single cause. It commonly involves both partners and requires a comprehensive approach to diagnosis and treatment." - Sharma et al., JNMA, 2025
4. Laparoscopic Findings in Nepal
A cross-sectional study at Nobel Medical College, Eastern Nepal (Subedi et al., JNMA, 2020, n=100 infertile women undergoing diagnostic laparoscopy) found:
- 62% - tubal disease (unilateral/bilateral obstruction)
- 63% - peritubal adhesions
- 50% - endometriosis (cysts, adhesions, obliteration of Pouch of Douglas)
- 15% - hydrosalpinx
This data reveals that pelvic infections and tubo-peritoneal disease - largely preventable through STI control and timely treatment of pelvic inflammatory disease - constitute the dominant female-factor burden in Nepal.
5. Psychological Impact in Nepal
A 2026 cross-sectional study in Kathmandu, Nepal (Dawadi et al., BMC Women's Health [PMID: 41709186]), of 182 infertile women found:
| Finding | Result |
|---|---|
| Prevalence of depressive symptoms | 38% |
| Moderate to severe depression | >10% |
Factors independently associated with depression in multivariate analysis:
- Husband's occupation
- Presence of chronic disease in the woman
- Lack of adequate emotional support from husband
Other associated factors (bivariate analysis):
- Ethnicity
- Husband's education level
- History of abortion
- Type of family (joint vs. nuclear)
- Rigid treatment schedule
"There is a necessity for specific psychological interventions for couples struggling with infertility to help them manage potential mental health problems and meet their reproductive goals." - Dawadi et al., BMC Women's Health, 2026
6. Socio-Cultural Context in Nepal
- Blame falls disproportionately on women regardless of actual cause, rooted in patriarchal cultural norms
- Infertility is associated with social ostracism, marital abandonment, domestic conflict, and discrimination
- Reliance on traditional healers and religious rituals is common, leading to delayed medical care
- Social stigma prevents couples - especially from rural, lower socioeconomic, and certain ethnic backgrounds - from seeking specialist help
- No national infertility registry or population-level epidemiological data exists
- Nepal's health system does not have infertility listed as a covered condition under standard insurance schemes
7. Healthcare Access and Services in Nepal
| Aspect | Status |
|---|---|
| Specialist infertility centers | Concentrated in Kathmandu Valley |
| Major hospitals with services | Paropakar Maternity & Women's Hospital, Dhulikhel Hospital, Tribhuvan University Teaching Hospital, Nobel Medical College (Biratnagar) |
| Laparoscopy | Available at select tertiary centers |
| IVF services | Available in Kathmandu; high out-of-pocket cost |
| State subsidy for ART | Not available |
| National fertility registry | Absent |
| Rural access | Severely limited |
8. Key Research Gaps in Nepal
- No national community-based prevalence study exists
- No data on environmental and occupational determinants of infertility (especially for labor migrants)
- Inadequate data on male infertility management outcomes
- No formal ART registry tracking IVF/ICSI outcomes
- Psychological and counseling services are largely absent from routine infertility care
FREQUENTLY ASKED QUESTIONS (FAQs)
Q1. What is infertility?
Infertility is defined as failure to achieve a clinical pregnancy after 12 or more months of regular, unprotected sexual intercourse. In women aged 35 or older, evaluation is recommended after 6 months. The WHO classifies it as a disease of the reproductive system. It should not be confused with sterility, which implies a permanent, irreversible inability to reproduce.
Q2. How common is infertility globally?
Approximately 17.5% of the global adult population is affected by infertility at some point in their reproductive life - roughly 1 in 6 people worldwide. An estimated 48-72 million couples are affected. Prevalence is broadly similar in high- and low-income countries, though the causes differ significantly. (Harrison's 2025; WHO 2023)
Q3. Is infertility only a woman's problem?
No. Male factors account for 40-50% of all infertility cases, female factors for 30-40%, and in 20-30% of couples, both partners have contributing issues. Evaluating only the woman while ignoring the male partner is a major clinical error. (Harrison's 2025, p. 3193)
Q4. What is the difference between primary and secondary infertility?
- Primary infertility - the couple has never conceived at all
- Secondary infertility - the couple has had at least one previous pregnancy but cannot conceive again
In Nepal, approximately 73-75% of hospital cases are primary infertility, making it the dominant pattern. (Sharma et al. 2025; Tamrakar & Bastakoti 2019)
Q5. What are the most common causes of female infertility?
The most common causes are:
- Ovulatory disorders - especially PCOS (affects about 8-13% of women of reproductive age), diminished ovarian reserve, and premature ovarian insufficiency
- Tubal disease - accounts for 30-35% of female infertility; mainly from prior pelvic infections (PID/STIs), endometriosis, or surgery
- Uterine pathology - fibroids, polyps, congenital anomalies, intrauterine adhesions
- Endocrine disorders - hypothyroidism, hyperprolactinemia
In Nepal specifically, ovulatory disorders (52%) and tubal disease (21-62% depending on study method) are the leading female causes.
Q6. What are the most common causes of male infertility?
- Varicocele - the single most common and most treatable structural cause
- Abnormal semen parameters - oligospermia (low count), asthenospermia (poor motility), teratospermia (abnormal morphology)
- Ductal obstruction - post-infection or post-vasectomy
- Genetic causes - Klinefelter syndrome, Y-chromosome microdeletions
- Hormonal imbalance - hypogonadism, thyroid disorders
- Lifestyle factors - smoking, anabolic steroid use, heat exposure, obesity
In Nepal, oligospermia is the most commonly identified semen abnormality (14.71%). (Sharma et al. 2025)
Q7. At what age does fertility decline?
Female fertility peaks at age 25 and begins declining after age 30, with a steep decline after 35. By ages 40-41, fecundability is reduced by 53% compared to women aged 30-31. Male fertility declines more gradually but is generally well-preserved before age 50.
Globally, the trend toward later marriage and delayed childbearing is a growing contributor to infertility rates, particularly in urban Nepal and South Asia.
Q8. How is infertility investigated?
Both partners should be evaluated simultaneously with:
- Male: Semen analysis (at least 2 samples, 4 weeks apart)
- Female:
- Hormone tests: FSH, LH, Estradiol (day 2-3 of cycle), AMH, TSH, Prolactin
- Ovulation confirmation: Serum progesterone (day 21), urinary LH kits
- Pelvic ultrasound: Uterus, ovaries, antral follicle count
- HSG (Hysterosalpingogram): Tubal patency
- Saline infusion sonogram: Intrauterine pathology
- Laparoscopy: Gold standard for pelvic/tubal disease (selective use)
(Harrison's 2025, p. 3193-3194)
Q9. What does "unexplained infertility" mean?
It means that after a complete fertility evaluation of both partners, no identifiable cause is found. This occurs in up to 30% of infertile couples globally. Management typically involves ovarian stimulation combined with IUI, or proceeding to IVF.
Q10. What treatments are available for infertility?
Treatment is tailored to the specific cause:
| Problem | Treatment |
|---|---|
| Anovulation (PCOS) | Letrozole (1st line), clomiphene citrate, metformin as add-on |
| Tubal factor | IVF (preferred); surgical repair in selected cases |
| Endometriosis | Laparoscopic surgery + IVF |
| Male factor (mild-moderate) | IUI ± ovulation induction |
| Male factor (severe) | IVF + ICSI |
| Azoospermia | Surgical sperm retrieval (TESA/TESE) + ICSI |
| Diminished ovarian reserve | IVF; donor oocytes |
| Hyperprolactinemia | Cabergoline/bromocriptine |
| Thyroid disorder | Levothyroxine first |
| Unexplained | IUI cycles → IVF |
(Harrison's 2025, p. 3194-3195)
Q11. What is IVF and how does it work?
IVF (In Vitro Fertilization) is the most effective ART:
- Ovarian stimulation with injectable hormones (FSH/LH)
- Egg retrieval under ultrasound guidance (vaginal approach, local/IV sedation)
- Fertilization in the laboratory (conventional or ICSI for male factor)
- Embryo culture for 3-5 days
- Transfer of one or more embryos into the uterus
- Pregnancy test 2 weeks later
Success rates depend on the woman's age, ovarian reserve, cause of infertility, and center experience.
Q12. Does infertility affect mental health?
Significantly, yes. A global review of 366 studies (Braverman et al., Fertility & Sterility, 2024 [PMID: 38224730]) confirmed that depression, anxiety, and reduced quality of life are consistent findings in infertile men and women across all cultures.
In Nepal specifically, 38% of infertile women in Kathmandu had depressive symptoms, with over 10% experiencing moderate to severe depression (Dawadi et al., BMC Women's Health, 2026 [PMID: 41709186]). Psychological counseling should be integrated into all infertility care pathways.
Q13. Is infertility preventable?
Many causes are preventable or modifiable:
| Risk Factor | Preventive Action |
|---|---|
| STIs/PID | Safe sex practices, early treatment of STIs |
| Smoking | Cessation restores much of the fertility damage |
| Obesity | Weight loss improves ovulation and sperm quality |
| High caffeine | Limit to ≤2 cups/day |
| Anabolic steroids | Discontinue (suppresses sperm production) |
| Thyroid disease | Regular monitoring and treatment |
| Delayed childbearing | Awareness of age-related decline (not always modifiable) |
Q14. When should a couple in Nepal seek help?
- Under 35 years: After 12 months of regular unprotected intercourse without conception
- Ages 35-39: After 6 months
- Age 40 or older: Seek evaluation immediately
- At any age if there is a known risk factor: prior PID, irregular or absent periods, prior pelvic surgery, prior STI, known male factor, prior miscarriages
Do not wait and hope for a year if risk factors are present. Early evaluation at a tertiary center is advisable for couples in Nepal, given the high prevalence of tubal disease and PCOS.
Q15. Are sperm counts declining globally?
Yes. A 2023 meta-analysis by Levine et al. (Human Reproduction Update [PMID: 36377604]) - one of the most comprehensive analyses ever done on this topic - found a significant decline in sperm counts in men from multiple continents over the 20th and 21st centuries. The causes likely include environmental factors (endocrine disruptors, pesticides), sedentary lifestyle, obesity, and heat exposure. This has long-term implications for global fertility rates.
REFERENCES
Textbooks:
-
Harrison's Principles of Internal Medicine, 22nd Edition (2025). McGraw-Hill. Chapter 408: Infertility and Contraception, pp. 3193-3196. (ISBN: 9781265977061)
-
Goldman-Cecil Medicine International Edition. Elsevier. Chapter 218: Infertility, pp. 2561-2562. (ISBN: 9780323930345)
Nepal-Specific Studies:
-
Sharma J, Shrestha D, Thapa D, Rawal S, Kafle R. Clinical Profile of Patients with Infertility Presenting to Tertiary Care Center: An Observational Study. JNMA J Nepal Med Assoc. 2025 Mar. doi:10.31729/jnma.8925. [PMID: 40656916] - 170 couples, Dec 2023-May 2024. Most recent Nepal clinical profile study.
-
Dawadi P, Shrestha S, Dawadee P, Gautam R. Psychological impact of infertility on women in Kathmandu, Nepal: a cross-sectional study of depressive symptoms and associated factors. BMC Women's Health. 2026 Feb. doi:10.1186/s12905-026-04349-7. [PMID: 41709186] - 182 women. Most recent Nepal psychological study.
-
Tamrakar SR, Bastakoti R. Determinants of Infertility in Couples. J Nepal Health Res Counc. 2019 Apr;17(1):99-103. doi:10.33314/jnhrc.1827. [PMID: 31110383] - 3,231 couples, Dhulikhel Hospital 2008-2018. Largest Nepal infertility series.
-
Subedi SS, Bhansakarya R, Shrestha P, Sharma SK. Outcome of Laparoscopy in Infertile Couples attending a Teaching Hospital in Eastern Nepal. JNMA J Nepal Med Assoc. 2020. doi:10.31729/jnma.5542. [PMID: 34506402] - 100 women, Nobel Medical College.
Global Evidence:
-
Braverman AM, Davoudian T, Levin IK, Bocage A, Wodoslawsky S. Depression, anxiety, quality of life, and infertility: a global lens on the last decade of research. Fertil Steril. 2024 Mar;121(3):383-398. doi:10.1016/j.fertnstert.2024.01.013. [PMID: 38224730]
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Levine H, Jørgensen N, Martino-Andrade A, et al. Temporal trends in sperm count: a systematic review and meta-regression analysis of samples collected globally in the 20th and 21st centuries. Hum Reprod Update. 2023;29(2):157-176. [PMID: 36377604]
-
World Health Organization (WHO). Infertility Fact Sheet. 2023. Available at who.int/reproductivehealth
Note on Nepal data: All Nepal figures are from hospital-based tertiary center studies and reflect presenting populations - they are not population-level prevalence estimates. A national community-based infertility epidemiology study in Nepal remains an unmet research need.
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